Healthcare Provider Details

I. General information

NPI: 1528383841
Provider Name (Legal Business Name): SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 03/30/2010
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: 918-488-0940
Mailing address:
  • Phone: 918-492-8200
  • Fax: 918-492-2849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number25487
License Number StateOK

VIII. Authorized Official

Name: KEVIN BURGESS
Title or Position: CEO
Credential:
Phone: 918-492-8200