Healthcare Provider Details

I. General information

NPI: 1912442070
Provider Name (Legal Business Name): BLUEMOON HEALTH MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 BUFFALO AVE SUITE 3B
BROOKLYN NY
11213-3283
US

IV. Provider business mailing address

196 BUFFALO AVE APT 3B
BROOKLYN NY
11213-3282
US

V. Phone/Fax

Practice location:
  • Phone: 585-709-3388
  • Fax:
Mailing address:
  • Phone: 585-709-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN KNIGHT
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 585-709-3388