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General NPI Number Information
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NPI Number | 1043027964
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Entity Type | Organization
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Legal Business Name | MOONAH INC
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Dates
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Enumeration Date | 12/13/2024
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 82 GRISWOLD DR
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City | WEST HARTFORD
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State | CT
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Zip | 06119-3549
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Country | US
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Telephone | 302-267-4679
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Fax |
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Provider Business Mailing Address
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Address Line | 82 GRISWOLD DR
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City | WEST HARTFORD
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State | CT
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Zip | 06119-1146
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Country | US
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Telephone | 251-223-2212
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Fax |
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Authorized Official
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Title or Position | CO -FOUNDER
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Name | LUKE A KIST
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Credential |
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Telephone | 251-223-2212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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