MOONLIGHT SUPPORT SERVICES LLC (NPI# 1164055026) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
Nation Provider ID (NPI) | 1164055026 |
Entity Type | Organization |
Organization Name | MOONLIGHT SUPPORT SERVICES LLC |
Practice Address |
3110 Old Hwy 8 206 Roseville MN 55113-5511 |
Mailing Address |
5913 Pleasant Ave Ste 104 Minneapolis MN 55419-2357 |
Practice Telephone | 6023234873 |
Enumeration Date | 2020-02-19 |
Last Update Date | 2020-02-19 |
Authorized Official Name | ABDIRAZAQ IBRAHIM (OWNER) |
Authorized Official Telephone | 6023234873 |
Is Organization Subpart | N |
Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
---|---|---|---|---|---|
Y | 261QM0855X |
Clinic/Center Specialization: Adolescent and Children Mental Health |
Ambulatory Health Care Facilities |
Street Address |
3110 OLD HWY 8 206 |
City | ROSEVILLE |
State | MN |
Zip Code | 55113-5511 |
NPI | Name | Taxonomy | Address | Enumeration |
---|---|---|---|---|
1396384376 | Zachary Mattson | Physician Assistant | Regus Coworking Space 2355 Highway 36 West, Suite 400, Office #427, Roseville, MN 55113 | 2019-12-23 |
1467010330 | Ahmed Issa | Student in an Organized Health Care Education/Training Program | 1550 Larpenteur Ave W, Apt 235, St Paul, MN 55113 | 2019-06-05 |
1821653833 | Suite Living Senior Care of Little Canada | Assisted Living Facility | 2740 Rice Street, Little Canada, MN 55113 | 2019-05-06 |
1902370505 | Diverse Assessments and Treatment, LLC | Psychologist | 1935 Cty Rd B2 W Ste 270, Roseville, MN 55113 | 2019-01-16 |
1588138473 | Applewood Home Health Care, LLC | Home Health | 2021 E Hennepin Avenue # 402-1, Minneapolis, MN 55113 | 2019-01-14 |
1699251520 | Optum Infusion Services 500, Inc. | Durable Medical Equipment & Medical Supplies | 2685 Patton Rd, Roseville, MN 55113 | 2018-07-13 |
1083104145 | Suite Living Senior Care of Roseville | Assisted Living Facility | 197 County Road B2 W, Roseville, MN 55113 | 2018-05-15 |
1477055796 | Sunrise Residential Services LLC | Home Health | 216 Maple Ln, Roseville, MN 55113 | 2018-03-02 |
1194223024 | Alissa Hoff | Specialist | 1595 Mn 36 - 584 10 Rosedale Center, Roseville, MN 55113 | 2018-01-25 |
1841705118 | Kingsland Care Services Incorporated | Case Management | 2301 Rice Street, Suite 101, Roseville, MN 55113 | 2017-12-08 |
Find all providers in zip 55113 |
Taxonomy Code | 261QM0855X |
Grouping | Ambulatory Health Care Facilities |
Classification | Clinic/Center |
Specialization | Adolescent and Children Mental Health |
An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in children and adolescents. Services may be provided to parents and family members of the patient in the form of conjoint, group, or individual therapy, and education and/or training. |
Notes: [7/1/2003: new] |
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Find all providers with the same taxonomy |
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Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.