Provider Demographics
NPI:1689192429
Name:ONE MOON INC
Entity Type:Organization
Organization Name:ONE MOON INC
Other - Org Name:VITA WHOLE BODY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:631-875-7200
Mailing Address - Street 1:820 SUFFOLK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4498
Mailing Address - Country:US
Mailing Address - Phone:631-524-5224
Mailing Address - Fax:
Practice Address - Street 1:750 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1239
Practice Address - Country:US
Practice Address - Phone:631-364-9075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty