NPIMap

Organization Active NPI

Mountain Shadows Support Group, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Escondido, CA
National Provider Identifier
1396860540
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
46989489 Issued in CA
Legal business name
MOUNTAIN SHADOWS SUPPORT GROUP, INC.
Practice address
2067 W El Norte Pkwy
Escondido, CA 92026-1810
Phone
(760) 743-3714
Fax
(760) 743-9937
NPI assigned
Mar 20, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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 46989489 CA Primary

Addresses

Primary practice location

2067 W El Norte Pkwy
Escondido, CA 92026-1810

Mailing address

2067 W El Norte Pkwy
Escondido, CA 92026-1810
Phone (760) 743-3714

Other identifiers 1

IdentifierTypeStateIssuer
LTC60158IMedicaidCA

Other names 1

  • Mtn.Shadows Community Homes-Crepe Myrtle 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 05G203

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
MTN SHADOWS COMM HOMES - CREPE MYRTLE
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Dec 23, 1985
Last certification
Jun 5, 2025
Beds
6
Ownership / control type
Private (non-profit)
Facility address
2067 W El Norte Parkway
Escondido, CA 92026

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

NPI Registry JSON

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

{
    "created_epoch": "1174348800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1396860540",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2067 W EL NORTE PKWY",
            "city": "ESCONDIDO",
            "state": "CA",
            "postal_code": "920261810",
            "telephone_number": "760-743-3714",
            "fax_number": "760-743-9937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2067 W EL NORTE PKWY",
            "city": "ESCONDIDO",
            "state": "CA",
            "postal_code": "920261810",
            "telephone_number": "760-743-3714",
            "fax_number": "760-743-9937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN SHADOWS SUPPORT GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-20",
        "last_updated": "2020-08-22",
        "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": "CA",
            "license": "46989489",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LTC60158I",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mtn.Shadows Community Homes-Crepe Myrtle",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Escondido, CA

Sources for this page

Verify at the official NPI Registry.