Provider Demographics
NPI:1760621007
Name:SHADOW MOUNTAIN LLC.
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN LLC.
Other - Org Name:SHADOW MOUNTAIN RECOVERY, ALBUQUERQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-389-8591
Mailing Address - Street 1:5400 GIBSON BLVD. S.E
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109
Mailing Address - Country:US
Mailing Address - Phone:505-867-0214
Mailing Address - Fax:
Practice Address - Street 1:5400 GIBSON BLVD. S. E
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-296-8184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility