Healthcare Provider Details

I. General information

NPI: 1104207760
Provider Name (Legal Business Name): MOONLITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 EAGLERIDGE BLVD STE 120
PUEBLO CO
81008-2354
US

IV. Provider business mailing address

805 EAGLERIDGE BLVD STE 120
PUEBLO CO
81008-2354
US

V. Phone/Fax

Practice location:
  • Phone: 970-209-0223
  • Fax:
Mailing address:
  • Phone: 970-209-0223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JUDY DEVINCENTIS
Title or Position: MEMBER
Credential:
Phone: 970-209-0223