Provider Demographics
NPI:1790181592
Name:MTN. SHADOWS ANCILLARY SERVICES
Entity Type:Organization
Organization Name:MTN. SHADOWS ANCILLARY SERVICES
Other - Org Name:SPECTRUM SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-743-3714
Mailing Address - Street 1:970 LOS VALLECITOS BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1473
Mailing Address - Country:US
Mailing Address - Phone:760-743-3714
Mailing Address - Fax:
Practice Address - Street 1:970 LOS VALLECITOS BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1473
Practice Address - Country:US
Practice Address - Phone:760-743-3714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABL12021639OtherBUSINESS LICENSE