Provider Demographics
NPI:1801226709
Name:SHADOW MOUNTAIN LLC.
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN LLC.
Other - Org Name:SHADOW MOUNTAIN RECOVERY, COLORADO SPRINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
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:PO BOX 830525
Mailing Address - Street 2:DEPARTMENT # SF 58
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:931-451-7757
Mailing Address - Fax:931-933-7762
Practice Address - Street 1:1155 KELLY JOHNSON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3932
Practice Address - Country:US
Practice Address - Phone:719-418-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1746-01251S00000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health