Provider Demographics
NPI:1396440616
Name:MOONLIGHT TREATMENT CENTER
Entity type:Organization
Organization Name:MOONLIGHT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-316-6495
Mailing Address - Street 1:9209 W MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-5597
Mailing Address - Country:US
Mailing Address - Phone:770-316-6495
Mailing Address - Fax:
Practice Address - Street 1:341 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1613
Practice Address - Country:US
Practice Address - Phone:770-316-6495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)