Provider Demographics
NPI:1437880333
Name:MOONLIGHT ORTHOTICS LLC
Entity Type:Organization
Organization Name:MOONLIGHT ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA HOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-516-0850
Mailing Address - Street 1:1926 HOLLYWOOD BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4543
Mailing Address - Country:US
Mailing Address - Phone:954-516-0850
Mailing Address - Fax:954-516-0870
Practice Address - Street 1:1926 HOLLYWOOD BLVD STE 301
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4543
Practice Address - Country:US
Practice Address - Phone:954-516-0850
Practice Address - Fax:954-516-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies