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General NPI Number Information
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NPI Number | 1992107221
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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 | 09/18/2014
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Last Update Date | 03/23/2016
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Provider Practice Location Address
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Address Line | 689 DANE DR
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City | SAN MARCOS
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State | CA
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Zip | 92069-5825
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Country | US
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Telephone | 760-743-3714
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Fax | 760-736-4173
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Provider Business Mailing Address
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Address Line | 970 LOS VALLECITOS BLVD STE 240
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City | SAN MARCOS
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State | CA
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Zip | 92069-1475
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Country | US
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Telephone | 760-743-3714
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Fax | 760-736-4173
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | WADE WILDE
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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 | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 550003036
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License Number State | CA
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