Healthcare Provider Details

I. General information

NPI: 1790181592
Provider Name (Legal Business Name): MTN. SHADOWS ANCILLARY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LOS VALLECITOS BLVD SUITE 140
SAN MARCOS CA
92069-1473
US

IV. Provider business mailing address

970 LOS VALLECITOS BLVD SUITE 240
SAN MARCOS CA
92069-1473
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ARLENE GALVAN
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 760-743-3714