Provider Demographics
NPI:1477208452
Name:SHADOW MOUNTAIN HEALTH LLC.
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN HEALTH LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-389-8591
Mailing Address - Street 1:104 S WAYNE AVE UNIT 371
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-6026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7005 PROSPECT PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4311
Practice Address - Country:US
Practice Address - Phone:925-389-8591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHADOW MOUNTAIN RECOVERY LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service