Healthcare Provider Details

I. General information

NPI: 1992170211
Provider Name (Legal Business Name): JIMMY MOON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16541 SWEETWATER DR
MILTON DE
19968-3062
US

IV. Provider business mailing address

16541 SWEETWATER DR
MILTON DE
19968-3062
US

V. Phone/Fax

Practice location:
  • Phone: 302-500-0950
  • Fax:
Mailing address:
  • Phone: 302-500-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2015102773
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: