Provider Demographics
NPI:1932563194
Name:MOUNTAIN SHADOWS SUPPORT GROUP
Entity Type:Organization
Organization Name:MOUNTAIN SHADOWS SUPPORT GROUP
Other - Org Name:MOUNTAIN SHADOWS SPECIAL KIDS HOMES-JOSHUA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYSON
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 1:7719 JOSHUA RD.
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-3317
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:2016-04-13
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility