Healthcare Provider Details

I. General information

NPI: 1760621007
Provider Name (Legal Business Name): SHADOW MOUNTAIN LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD. S. E 3RD FLOOR
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

5400 GIBSON BLVD. S.E 3RD FLOOR
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-8184
  • Fax:
Mailing address:
  • Phone: 505-867-0214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JACKIE HOLUB
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 925-389-8591