Provider Demographics
NPI:1164055026
Name:MOONLIGHT SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:MOONLIGHT SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDIRAZAQ
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-323-4873
Mailing Address - Street 1:5913 PLEASANT AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3110 OLD HWY 8
Practice Address - Street 2:206
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5511
Practice Address - Country:US
Practice Address - Phone:602-323-4873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health