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General NPI Number Information
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NPI Number | 1760621007
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Entity Type | Organization
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Legal Business Name | SHADOW MOUNTAIN LLC.
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Dates
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Enumeration Date | 02/10/2009
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Last Update Date | 10/28/2015
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Provider Practice Location Address
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Address Line | 5400 GIBSON BLVD. S. E 3RD FLOOR
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City | ALBUQUERQUE
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State | NM
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Zip | 87109
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Country | US
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Telephone | 505-296-8184
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Fax |
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Provider Business Mailing Address
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Address Line | 5400 GIBSON BLVD. S.E 3RD FLOOR
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City | ALBUQUERQUE
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State | NM
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Zip | 87109
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Country | US
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Telephone | 505-867-0214
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Fax |
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | JACKIE HOLUB
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Credential |
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Telephone | 925-389-8591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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