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General NPI Number Information
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NPI Number | 1952618308
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Entity Type | Organization
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Legal Business Name | REACH FOR THE MOON INC
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Dates
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Enumeration Date | 09/07/2010
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Last Update Date | 09/07/2010
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Provider Practice Location Address
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Address Line | 714 BASKINS CIR
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City | WINDER
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State | GA
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Zip | 30680-3584
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Country | US
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Telephone | 678-425-9602
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Fax |
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Provider Business Mailing Address
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Address Line | 714 BASKINS CIR
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City | WINDER
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State | GA
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Zip | 30680-3584
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Country | US
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Telephone | 678-425-9602
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. MELVIN MOON SR.
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Credential |
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Telephone | 678-425-3231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 129815246A
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License Number State | GA
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