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General NPI Number Information
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NPI Number | 1861517005
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Entity Type | Organization
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Legal Business Name | MOUNTAIN SHADOWS SUPPORT GROUP, INC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 12/26/2007
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Provider Practice Location Address
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Address Line | 4840 FAIRHILL PLACE
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City | RIVERSIDE
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State | CA
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Zip | 92026
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Country | US
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Telephone | 760-743-3714
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Fax | 760-743-9937
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Provider Business Mailing Address
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Address Line | 2067 W EL NORTE PKWY
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City | ESCONDIDO
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State | CA
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Zip | 92026-1810
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Country | US
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Telephone | 760-743-3714
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Fax | 760-743-9937
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Authorized Official
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Title or Position | BUSINESS OFFICE MANAGER
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Name | LUPE BRYSON
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Credential |
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Telephone | 760-743-3714
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 46989489
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License Number State | CA
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