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General NPI Number Information
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NPI Number | 1164055026
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Entity Type | Organization
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Legal Business Name | MOONLIGHT SUPPORT SERVICES LLC
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Dates
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Enumeration Date | 02/19/2020
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Last Update Date | 02/19/2020
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Provider Practice Location Address
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Address Line | 3110 OLD HWY 8 206
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City | ROSEVILLE
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State | MN
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Zip | 55113-5511
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Country | US
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Telephone | 602-323-4873
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Fax |
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Provider Business Mailing Address
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Address Line | 5913 PLEASANT AVE STE 104
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City | MINNEAPOLIS
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State | MN
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Zip | 55419-2357
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ABDIRAZAQ IBRAHIM
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Credential |
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Telephone | 602-323-4873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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