Provider Demographics
NPI:1003046566
Name:SHADY GLEN FACILITY
Entity type:Organization
Organization Name:SHADY GLEN FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-910-9604
Mailing Address - Street 1:2571 SHADY GLEN LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4174
Mailing Address - Country:US
Mailing Address - Phone:909-783-8806
Mailing Address - Fax:
Practice Address - Street 1:2571 SHADY GLEN LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4174
Practice Address - Country:US
Practice Address - Phone:909-783-8806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGES IN COMMUNICATIONS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-19
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360911227261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities