Healthcare Provider Details

I. General information

NPI: 1093879009
Provider Name (Legal Business Name): NEW MOON MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W LEXINGTON AVE SUITE B
WINCHESTER KY
40391-1127
US

IV. Provider business mailing address

PO BOX 331
WINCHESTER KY
40392-0331
US

V. Phone/Fax

Practice location:
  • Phone: 859-737-5154
  • Fax: 877-737-1881
Mailing address:
  • Phone: 859-737-5154
  • Fax: 877-737-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number184257
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: BEN WORTHINGTON
Title or Position: PRESIDENT
Credential:
Phone: 859-737-5154