Provider Demographics
NPI:1366430910
Name:SHADOW MOUNTAIN MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:SHADOW MOUNTAIN MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWNSEND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-275-8656
Mailing Address - Street 1:1401 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2303
Mailing Address - Country:US
Mailing Address - Phone:719-275-8656
Mailing Address - Fax:
Practice Address - Street 1:1401 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2303
Practice Address - Country:US
Practice Address - Phone:719-275-8656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0055314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05653571Medicaid
CO42337071OtherRESPITE PROVIDER NUMBER
CO065179Medicare ID - Type Unspecified