Healthcare Provider Details

I. General information

NPI: 1144167529
Provider Name (Legal Business Name): MOONLIGHT ELECTROLYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 E PORTLAND RD STE 206
NEWBERG OR
97132-1852
US

IV. Provider business mailing address

904 NW YAMHILL ST
MCMINNVILLE OR
97128-5061
US

V. Phone/Fax

Practice location:
  • Phone: 971-258-0035
  • Fax:
Mailing address:
  • Phone: 971-258-0035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MARK KENNETH SMITH
Title or Position: BUSINESS OWNER
Credential: LE
Phone: 971-258-0035