Moonlight Support Services LLC
Clinic/Center, Adolescent and Children Mental Health in Roseville, MN. Organization (NPI-2).
NPI number1164055026
StatusActive
Last updated in NPPESFeb 19, 2020
Details
- NPI
- 1164055026
- Entity type
- Organization (NPI-2)
- Legal business name
- Moonlight Support Services LLC
- Organization subpart
- No
- Enumeration date
- Feb 19, 2020
- Certification date
- Feb 19, 2020
- Last updated
- Feb 19, 2020
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 261QM0855X | Clinic/Center, Adolescent and Children Mental Health | – | – | Yes |
Practice location
3110 Old Hwy 8206
Roseville, MN 55113-5511
Phone 602-323-4873
Mailing address
5913 Pleasant Ave Ste 104Minneapolis, MN 55419-2357
Authorized official
Abdirazaq Ibrahim
Owner
6023234873
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