Healthcare Provider Details

I. General information

NPI: 1851781058
Provider Name (Legal Business Name): MOONLIGHT HOME HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SELKIRK DR APT 310C
BURNSVILLE MN
55337-5676
US

IV. Provider business mailing address

2800 SELKIRK DR APT 310C
BURNSVILLE MN
55337-5676
US

V. Phone/Fax

Practice location:
  • Phone: 651-347-3096
  • Fax:
Mailing address:
  • Phone: 651-347-3096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: ASAD SALAH ABDALLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 651-347-3096