Healthcare Provider Details

I. General information

NPI: 1093597619
Provider Name (Legal Business Name): BEAUTIFUL MOON HEALTH & WELLNESS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19590 E MAINSTREET STE 202
PARKER CO
80138-7371
US

IV. Provider business mailing address

18121 E HAMPDEN AVE STE C1079
AURORA CO
80013-3590
US

V. Phone/Fax

Practice location:
  • Phone: 720-544-3801
  • Fax:
Mailing address:
  • Phone: 720-544-3801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JAVONNI HENDERSON
Title or Position: OWNER
Credential: LCSW
Phone: 510-256-9794