Organization
MOUNTAIN SHADOWS SUPPORT GROUP
Active
Other names
Mtn. Shadows Community Homes- Fig House
Organization subpart
No
Provider details
NPI number
Authorized official
WADE WILDE (EXECUTIVE DIRECTOR)
(760) 743-3714
Entity
Organization
Contact information
Practice address
689 DANE DR, SAN MARCOS, CA 92069-5825
(760) 743-3714
(760) 736-4173
Mailing address
970 LOS VALLECITOS BLVD STE 240, SAN MARCOS, CA 92069-1475
(760) 743-3714
(760) 736-4173
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
550003036
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
550003036
—
CA
Enumeration date
09/18/2014
Last updated
03/23/2016
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