=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750177481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOXIE MEDISPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N72W13350 LUND LN
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-4674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-350-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N72W13350 LUND LN
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-4674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-350-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | ALEX AMANDA FOLEY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 414-322-5643
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------