NPIMap

Organization Active NPI

Mountain Shadows Support Group, Inc.

Doing business as Special Kids Homes-Glen House

  • Nursing Facility/Intermediate Care Facility
  • Riverside, CA
National Provider Identifier
1750406070
Registry record updated Feb 15, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X
License
46989489 Issued in CA
Legal business name
MOUNTAIN SHADOWS SUPPORT GROUP, INC.
Doing business as
Special Kids Homes-Glen House
Practice address
4680 Glen St
Riverside, CA 92509-3005
Phone
(760) 743-3714
Fax
(760) 743-9937
NPI assigned
Mar 20, 2007
Last updated
Feb 15, 2008By the provider in NPPES
Organization subpart
Yes
Parent organization
MOUNTAIN SHADOWS SUPPORT GROUP.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 15, 2008

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
Nursing Facility/Intermediate Care Facility 313M00000X 46989489 CA Primary

Addresses

Primary practice location

4680 Glen St
Riverside, CA 92509-3005

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
LTC80008GMedicaidCA
LTC80008HMedicaidCA

Other names 1

  • Special Kids Homes-Glen House Doing business as

National Provider Directory

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

Other organizations with this tax ID 34

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

View all 34

Locations

4680 Galena St
Riverside, CA 92509

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": "1203033600000",
    "number": "1750406070",
    "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": "4680 GLEN ST",
            "city": "RIVERSIDE",
            "state": "CA",
            "postal_code": "925093005",
            "telephone_number": "760-743-3714",
            "fax_number": "760-743-9937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN SHADOWS SUPPORT GROUP, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNTAIN SHADOWS SUPPORT GROUP.",
        "enumeration_date": "2007-03-20",
        "last_updated": "2008-02-15",
        "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": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "CA",
            "license": "46989489",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LTC80008G",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LTC80008H",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Special Kids Homes-Glen House",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Riverside, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.