Provider Demographics
NPI:1225897317
Name:MOONSTONE RECOVERY INC.
Entity Type:Organization
Organization Name:MOONSTONE RECOVERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:FAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-456-7337
Mailing Address - Street 1:845 HENNESSEY WAY
Mailing Address - Street 2:
Mailing Address - City:PLUMAS LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95961-9224
Mailing Address - Country:US
Mailing Address - Phone:619-456-7337
Mailing Address - Fax:
Practice Address - Street 1:845 HENNESSEY WAY
Practice Address - Street 2:
Practice Address - City:PLUMAS LAKE
Practice Address - State:CA
Practice Address - Zip Code:95961-9224
Practice Address - Country:US
Practice Address - Phone:619-456-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility