| Organization Name: | SHADY GLEN FACILITY |
| NPI Number: | 1003046566 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PATRICIA STONE (ADMINISTRATOR) |
| Mailing Address: | 2571 Shady Glen Ln San Bernardino |
| State: | CA US |
| Postal Code: | 924084174 |
| Phone Number: | 9097838806 |
| Fax Number: | |
| NPI Enumeration Date: | 07/19/2009 |
| NPI Last Update Date: | 07/29/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD1600X |
| License Number: | 360911227 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Developmental Disabilities |
| Taxonomy Definition: | An entity, facility, or distinct part of a facility providing comprehensive, multidiscipline diagnostic, treatment, therapy, training, and counseling services to children with congenital disorders that precipitate developmental delays and in many instances mental deficiencies (e.g., Cerebral Palsy, metabolic disorders, Sturge-Weber Syndrome, etc.). |