Provider Demographics
NPI:1104207760
Name:MOONLITE, LLC
Entity type:Organization
Organization Name:MOONLITE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVINCENTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-209-0223
Mailing Address - Street 1:805 EAGLERIDGE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2354
Mailing Address - Country:US
Mailing Address - Phone:970-209-0223
Mailing Address - Fax:
Practice Address - Street 1:805 EAGLERIDGE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2354
Practice Address - Country:US
Practice Address - Phone:970-209-0223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76356523Medicaid