Healthcare Provider Details

I. General information

NPI: 1306121017
Provider Name (Legal Business Name): MOON RIVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 OAK TRAIL DR.
MARIETTA GA
30062-7502
US

IV. Provider business mailing address

790 OAK TRAIL DR.
MARIETTA GA
30062-7502
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-6866
  • Fax: 770-977-6887
Mailing address:
  • Phone: 770-977-6866
  • Fax: 770-977-6887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIA T SMITH
Title or Position: PRESIDENT
Credential: PT
Phone: 770-977-6866