Healthcare Provider Details

I. General information

NPI: 1366430910
Provider Name (Legal Business Name): SHADOW MOUNTAIN MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PHAY AVE
CANON CITY CO
81212-2303
US

IV. Provider business mailing address

1401 PHAY AVE
CANON CITY CO
81212-2303
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-8656
  • Fax:
Mailing address:
  • Phone: 719-275-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0055
License Number StateCO

VIII. Authorized Official

Name: SHELBY TOWNSEND
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 719-275-8656