Healthcare Provider Details

I. General information

NPI: 1891764940
Provider Name (Legal Business Name): JOHN A MOON LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 MAIN ST
COSHOCTON OH
43812-1615
US

IV. Provider business mailing address

73 E MAIN ST
NEW CONCORD OH
43762-1237
US

V. Phone/Fax

Practice location:
  • Phone: 740-454-9766
  • Fax: 740-588-6452
Mailing address:
  • Phone: 740-826-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS0010829
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: