Provider Demographics
NPI:1568245595
Name:MOONGLADE INTEGRATIVE LLC
Entity Type:Organization
Organization Name:MOONGLADE INTEGRATIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RESH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:240-321-2770
Mailing Address - Street 1:300 STIFF RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:PA
Mailing Address - Zip Code:15411-2057
Mailing Address - Country:US
Mailing Address - Phone:240-321-2770
Mailing Address - Fax:
Practice Address - Street 1:3233B CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1370
Practice Address - Country:US
Practice Address - Phone:240-321-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-15
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health