Healthcare Provider Details

I. General information

NPI: 1477208452
Provider Name (Legal Business Name): SHADOW MOUNTAIN HEALTH LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 PROSPECT PL NE
ALBUQUERQUE NM
87110-4311
US

IV. Provider business mailing address

104 S WAYNE AVE UNIT 371
WAYNE PA
19087-6026
US

V. Phone/Fax

Practice location:
  • Phone: 925-389-8591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACKIE ELLIOTT
Title or Position: VP OPERATIONS
Credential:
Phone: 925-389-8591