1730143553 NPI number — MOON RIVER, LLC

Table of content: (NPI 1730143553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730143553 NPI number — MOON RIVER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOON RIVER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730143553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 OAK TRAIL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-7502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-212-2170
Provider Business Mailing Address Fax Number:
770-783-8639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 OAK TRAIL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-7502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-977-6866
Provider Business Practice Location Address Fax Number:
770-977-6887
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
TERESA
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
770-977-6866

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT003833 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT008523 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT008507 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT001355 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT007864 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT005771 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT008924 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT004577 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X , with the licence number: OT 004293 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X , with the licence number: GAOT001717 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP003992 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP005806 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP006528 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP 06551 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP 006556 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 191707573A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 240960806A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 516643175A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 761415888A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 814363142A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000860736B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146855825A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 765677599A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 188883028B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 317872221A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 339518223A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 426315361A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 986209149B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000970835A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 481436178B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 503885675B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 850524466A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 315889908A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000753563E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 461168837A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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