Provider Demographics
NPI:1285162149
Name:TO THE MOON AND BACK PERSONAL CARE LLC
Entity type:Organization
Organization Name:TO THE MOON AND BACK PERSONAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:DAINE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-667-7320
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-0793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7318 GILLETT ST
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-6421
Practice Address - Country:US
Practice Address - Phone:915-667-7320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care