1932563194 NPI number — MOUNTAIN SHADOWS SUPPORT GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932563194 NPI number — MOUNTAIN SHADOWS SUPPORT GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN SHADOWS SUPPORT GROUP
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:
MOUNTAIN SHADOWS SPECIAL KIDS HOMES-JOSHUA
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:
1932563194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
970 LOS VALLECITOS BLVD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
SAN MARCOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92069-1473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-743-3714
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7719 JOSHUA RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JURUPA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92509-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-743-3714
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRYSON
Authorized Official First Name:
LUPE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
760-743-3714

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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