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General NPI Number Information
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NPI Number | 1932563194
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Entity Type | Organization
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Legal Business Name | MOUNTAIN SHADOWS SUPPORT GROUP
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Dates
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Enumeration Date | 04/13/2016
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Last Update Date | 05/06/2016
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Provider Practice Location Address
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Address Line | 7719 JOSHUA RD.
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City | JURUPA VALLEY
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State | CA
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Zip | 92509-3317
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Country | US
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Telephone | 760-743-3714
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Fax |
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Provider Business Mailing Address
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Address Line | 970 LOS VALLECITOS BLVD SUITE 240
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City | SAN MARCOS
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State | CA
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Zip | 92069-1473
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Country | US
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Telephone | 760-743-3714
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Fax |
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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 |
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License Number State | CA
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