Healthcare Provider Details

I. General information

NPI: 1942639539
Provider Name (Legal Business Name): MOON RIVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FIRST DR SUITE 340
MARIETTA GA
30062-7739
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: 770-783-8639
Mailing address:
  • Phone: 770-977-6866
  • Fax: 770-783-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

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