Provider Demographics
NPI:1396860540
Name:MOUNTAIN SHADOWS SUPPORT GROUP, INC.
Entity Type:Organization
Organization Name:MOUNTAIN SHADOWS SUPPORT GROUP, INC.
Other - Org Name:MTN.SHADOWS COMMUNITY HOMES-CREPE MYRTLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-743-3714
Mailing Address - Street 1:2067 W EL NORTE PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-1810
Mailing Address - Country:US
Mailing Address - Phone:760-743-3714
Mailing Address - Fax:760-743-9937
Practice Address - Street 1:2067 W EL NORTE PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-1810
Practice Address - Country:US
Practice Address - Phone:760-743-3714
Practice Address - Fax:760-743-9937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46989489315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60158IMedicaid