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General NPI Number Information
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NPI Number | 1316091457
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Entity Type | Organization
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Legal Business Name | SHADOW MOUNTAIN BEHAVIORAL HEALTH SYSTEM LLC
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 03/30/2010
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Provider Practice Location Address
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Address Line | 1027 E 66TH PL
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City | TULSA
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State | OK
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Zip | 74136-3701
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Country | US
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Telephone | 918-293-2552
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Fax |
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Provider Business Mailing Address
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Address Line | 1027 E 66TH PL
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City | TULSA
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State | OK
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Zip | 74136-3701
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Country | US
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Telephone | 918-293-2552
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MIKE KISTLER
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Credential |
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Telephone | 918-492-8200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | K8500227
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License Number State | OK
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