Provider Demographics
NPI:1306121017
Name:MOON RIVER, LLC
Entity type:Organization
Organization Name:MOON RIVER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-977-6866
Mailing Address - Street 1:790 OAK TRAIL DR.
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7502
Mailing Address - Country:US
Mailing Address - Phone:770-977-6866
Mailing Address - Fax:770-977-6887
Practice Address - Street 1:790 OAK TRAIL DR.
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7502
Practice Address - Country:US
Practice Address - Phone:770-977-6866
Practice Address - Fax:770-977-6887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOON RIVER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA223654765AMedicaid