Healthcare Provider Details

I. General information

NPI: 1629903265
Provider Name (Legal Business Name): MOMA PREMIUM SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 DAVID ST
WEST HAVEN CT
06516-1201
US

IV. Provider business mailing address

104 DAVID ST
WEST HAVEN CT
06516-1201
US

V. Phone/Fax

Practice location:
  • Phone: 203-507-3730
  • Fax: 203-507-3730
Mailing address:
  • Phone: 203-507-3730
  • Fax: 203-507-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: AHOUA CISSE
Title or Position: OWNER
Credential:
Phone: 203-507-3730