NPIMap

Organization Active NPI

Mountain Shadows Support Group, Inc

  • Nursing Facility/Intermediate Care Facility
  • Riverside, CA
National Provider Identifier
1861517005
Registry record updated Dec 26, 2007
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
Practice address
4840 Fairhill Place
Riverside, CA 92026
Phone
(760) 743-3714
Fax
(760) 743-9937
NPI assigned
Mar 20, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 26, 2007

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

4840 Fairhill Place
Riverside, CA 92026

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
LTC80158FMedicaidCA
LTC80158GMedicaidCA

Other names 1

  • Special Kids Homes-Baker House Former legal business name

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": "1198627200000",
    "number": "1861517005",
    "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": "4840 FAIRHILL PLACE",
            "city": "RIVERSIDE",
            "state": "CA",
            "postal_code": "92026",
            "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": "2007-12-26",
        "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": "LTC80158F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LTC80158G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Special Kids Homes-Baker House",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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 Dec 26, 2007; 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.