1831505874 NPI number — SHADOW MOUNTAIN LLC.

Table of content: (NPI 1831505874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831505874 NPI number — SHADOW MOUNTAIN LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADOW MOUNTAIN LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHADOW MOUNTAIN DETOX HOSPITAL, ST. GEORGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831505874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 830525
Provider Second Line Business Mailing Address:
DEPARTMENT # SF 59
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35283-0525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-451-7757
Provider Business Mailing Address Fax Number:
931-933-7762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W. 1470 SOUTH
Provider Second Line Business Practice Location Address:
BUILDING B
Provider Business Practice Location Address City Name:
ST. GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-272-0220
Provider Business Practice Location Address Fax Number:
435-272-0222
Provider Enumeration Date:
07/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HOLUB
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
925-389-8591

Provider Taxonomy Codes

  • Taxonomy code: 284300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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