Healthcare Provider Details

I. General information

NPI: 1396894291
Provider Name (Legal Business Name): MOUNTAIN SHADOWS SUPPORT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W EL NORTE PKWY
ESCONDIDO CA
92026-1810
US

IV. Provider business mailing address

2067 W EL NORTE PKWY
ESCONDIDO CA
92026-1810
US

V. Phone/Fax

Practice location:
  • Phone: 760-743-3714
  • Fax: 760-743-9937
Mailing address:
  • Phone: 760-743-3714
  • Fax: 760-743-9937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number090000253
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberLTC60136I
License Number StateCA

VIII. Authorized Official

Name: MRS. LUPE BRYSON
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 760-743-3714