MOON RIVER, LLC

Provider Demographics

• NPI: 1730143553
• Name: MOON RIVER, LLC
• Entity Type: Organization
• Organization Name: MOON RIVER, LLC
• Authorized Official - Title/Position: OFFICE ADMINISTRATOR
• Authorized Official - First Name: MARIA
• Authorized Official - Middle Name: TERESA
• Authorized Official - Last Name: SMITH
• Authorized Official - Phone: 770-977-6866
• Mailing Address - Street 1: 790 OAK TRAIL DR
• Mailing Address - City: MARIETTA
• Mailing Address - State: GA
• Mailing Address - Zip Code: 30062-7502
• Mailing Address - Country: US
• Mailing Address - Phone: 770-212-2170
• Mailing Address - Fax: 770-783-8639
• Practice Address - Street 1: 790 OAK TRAIL DR
• Practice Address - City: MARIETTA
• Practice Address - State: GA
• Practice Address - Zip Code: 30062-7502
• Practice Address - Country: US
• Practice Address - Phone: 770-977-6866
• Practice Address - Fax: 770-977-6887
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-04-17
• Last Update Date: 2017-02-15

Provider Licenses

State	License ID	Taxonomies
GA	PT003833	225100000X
GA	PT008523	225100000X
GA	PT008507	225100000X
GA	PT001355	225100000X
GA	PT007864	225100000X
GA	PT005771	225100000X
GA	PT008924	225100000X
GA	OT004577	225X00000X
GA	OT 004293	225XP0200X
GA	GAOT001717	225XP0200X
GA	SLP003992	235Z00000X
GA	SLP005806	235Z00000X
GA	SLP006528	235Z00000X
GA	SLP 06551	235Z00000X
GA	SLP 006556	235Z00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	225XP0200X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist	Pediatrics	Group - Multi-Specialty
No	225100000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist		Group - Multi-Specialty
No	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty
No	235Z00000X	Speech, Language and Hearing Service Providers	Speech-Language Pathologist		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
GA	191707573A	Medicaid
GA	240960806A	Medicaid
GA	516643175A	Medicaid
GA	761415888A	Medicaid
GA	814363142A	Medicaid
GA	000860736B	Medicaid
GA	146855825A	Medicaid
GA	765677599A	Medicaid
GA	188883028B	Medicaid
GA	317872221A	Medicaid
GA	339518223A	Medicaid
GA	426315361A	Medicaid
GA	986209149B	Medicaid
GA	000970835A	Medicaid
GA	481436178B	Medicaid
GA	503885675B	Medicaid
GA	850524466A	Medicaid
GA	315889908A	Medicaid
GA	000753563E	Medicaid
GA	461168837A	Medicaid