Provider Demographics
NPI:1376208819
Name:MOONBEAM WELLNESS LLC
Entity Type:Organization
Organization Name:MOONBEAM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSINOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:978-219-2968
Mailing Address - Street 1:6 LYNDE ST # 1A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3404
Mailing Address - Country:US
Mailing Address - Phone:978-219-2968
Mailing Address - Fax:978-209-3777
Practice Address - Street 1:6 LYNDE ST # 1A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3404
Practice Address - Country:US
Practice Address - Phone:978-219-2968
Practice Address - Fax:978-209-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-31
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)