Healthcare Provider Details

I. General information

NPI: 1184290199
Provider Name (Legal Business Name): MOONSTONE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E GRAND AVE UNIT 2
LARAMIE WY
82070-3604
US

IV. Provider business mailing address

PO BOX 2417
CHEYENNE WY
82003-2417
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-0300
  • Fax: 307-638-0394
Mailing address:
  • Phone: 307-638-0300
  • Fax: 307-638-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: LINDSAY STOFFERS
Title or Position: OWNER
Credential:
Phone: 307-399-0788