Healthcare Provider Details

I. General information

NPI: 1437521507
Provider Name (Legal Business Name): SHADOW MOUNTAIN RECOVERY LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 VILLA RD SE
RIO RANCHO NM
87124-3581
US

IV. Provider business mailing address

PO BOX 830525 DEPARTMENT # SF 64
BIRMINGHAM AL
35283-0525
US

V. Phone/Fax

Practice location:
  • Phone: 800-203-8249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JACKIE ELLIOTT
Title or Position: VICE PRESIDENT
Credential:
Phone: 925-389-8591