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General NPI Number Information
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NPI Number | 1689192429
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Entity Type | Organization
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Legal Business Name | ONE MOON INC
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Dates
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Enumeration Date | 08/31/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 750 ROUTE 25A
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City | EAST SETAUKET
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State | NY
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Zip | 11733-1239
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Country | US
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Telephone | 631-364-9075
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Fax |
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Provider Business Mailing Address
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Address Line | 820 SUFFOLK AVE STE 201
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City | BRENTWOOD
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State | NY
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Zip | 11717-4498
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Country | US
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Telephone | 631-524-5224
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Fax |
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Authorized Official
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Title or Position | ACUPUNCTURIST
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Name | MR. RANDY M GONZALES
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Credential | LAC
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Telephone | 631-875-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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