Provider Demographics
NPI:1396110219
Name:BLACK MOUNTAIN, LLC
Entity type:Organization
Organization Name:BLACK MOUNTAIN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-785-2800
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94011-0072
Mailing Address - Country:US
Mailing Address - Phone:650-785-2800
Mailing Address - Fax:650-785-2801
Practice Address - Street 1:177 BOVET RD
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3116
Practice Address - Country:US
Practice Address - Phone:650-785-2800
Practice Address - Fax:650-785-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health