Healthcare Provider Details

I. General information

NPI: 1982758538
Provider Name (Legal Business Name): SHADOW MOUNTAIN BEHAVIORAL HEALTH CARE SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 E 66TH PL
TULSA OK
74136-3701
US

IV. Provider business mailing address

6262 S SHERIDAN RD
TULSA OK
74133-4055
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-8200
  • Fax: 918-493-3268
Mailing address:
  • Phone: 918-492-8200
  • Fax: 918-493-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberK8500227
License Number StateOK

VIII. Authorized Official

Name: STEVE FILTON
Title or Position: SRVP CFO
Credential:
Phone: 610-768-3300