1811563604 NPI number — MOON WELLNESS GROUP, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811563604 NPI number — MOON WELLNESS GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOON WELLNESS GROUP, PLLC
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:
1811563604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3240 OLD HICKORY PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48104-5279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-707-3770
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2385 S HURON PKWY STE 2N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48104-5127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-681-0830
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOON
Authorized Official First Name:
MIEA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHD
Authorized Official Telephone Number:
734-681-0830

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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