Healthcare Provider Details

I. General information

NPI: 1811906944
Provider Name (Legal Business Name): MODIMOON ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 WATSON RD STE. LL2
SAINT LOUIS MO
63109-1251
US

IV. Provider business mailing address

3915 WATSON RD STE. LL2
SAINT LOUIS MO
63109-1251
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-9711
  • Fax:
Mailing address:
  • Phone: 314-781-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License NumberNA
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberNA
License Number StateMO

VIII. Authorized Official

Name: MS. JENNIFER MOON
Title or Position: PRESIDENT
Credential:
Phone: 314-781-9711