NPIMap

Organization Active NPI

Mountain Shadows Support Group

Doing business as Mountain Shadows Special Kids Homes-Garth

  • Intellectual Disabilities Intermediate Care Facility
  • Jurupa Valley, CA
National Provider Identifier
1104280361
Registry record updated Apr 19, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
Legal business name
MOUNTAIN SHADOWS SUPPORT GROUP
Doing business as
Mountain Shadows Special Kids Homes-Garth
Practice address
4287 Garth St
Jurupa Valley, CA 92509-3316
Phone
(760) 743-3714
NPI assigned
Apr 13, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 19, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lupe Bryson
Title
Business Office Manager
Phone
(760) 743-3714

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X Primary

Addresses

Primary practice location

4287 Garth St
Jurupa Valley, CA 92509-3316

Mailing address

970 Los Vallecitos Blvd
San Marcos, CA 92069-1473
Phone (760) 743-3714

Other names 1

  • MOUNTAIN SHADOWS SPECIAL KIDS HOMES-GARTH Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 55G756

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
MOUNTAIN SHADOWS SPECIAL KIDS HOMES - GARTH
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Oct 4, 2017
Last certification
Apr 30, 2025
Beds
6
Ownership / control type
Private (non-profit)
Facility address
4287 Garth Street
Jurupa Valley, CA 92509

National Provider Directory

National Provider Directory
Tax ID family
Mountain Shadows Support Group35 organizations share this tax ID, including this one

Other organizations with this tax ID 34

Organizations that report the same tax identification number in the National Provider Directory.

View all 34

Locations

4287 Garth St
Jurupa Valley, CA 92509

970 Los Vallecitos Blvd
San Marcos, CA 92069

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1460505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1461024000000",
    "number": "1104280361",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "970 LOS VALLECITOS BLVD",
            "city": "SAN MARCOS",
            "state": "CA",
            "postal_code": "920691473",
            "telephone_number": "760-743-3714"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4287 GARTH ST",
            "city": "JURUPA VALLEY",
            "state": "CA",
            "postal_code": "925093316",
            "telephone_number": "760-743-3714"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN SHADOWS SUPPORT GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-13",
        "last_updated": "2016-04-19",
        "status": "A",
        "authorized_official_last_name": "BRYSON",
        "authorized_official_first_name": "LUPE",
        "authorized_official_title_or_position": "BUSINESS OFFICE MANAGER",
        "authorized_official_telephone_number": "760-743-3714"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MOUNTAIN SHADOWS SPECIAL KIDS HOMES-GARTH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jurupa Valley, CA

Sources for this page

Verify at the official NPI Registry.