Provider Demographics
NPI:1588309942
Name:MOONSTAR BEHAVIORAL HME LLC
Entity type:Organization
Organization Name:MOONSTAR BEHAVIORAL HME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDI
Authorized Official - Middle Name:BASHIR
Authorized Official - Last Name:DOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-688-4946
Mailing Address - Street 1:5121 W SAN GABRIEL AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5410
Mailing Address - Country:US
Mailing Address - Phone:623-688-4946
Mailing Address - Fax:
Practice Address - Street 1:5121 W SAN GABRIEL AVE
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-5410
Practice Address - Country:US
Practice Address - Phone:623-688-4946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances