Provider Demographics
NPI:1942639539
Name:MOON RIVER, LLC
Entity Type:Organization
Organization Name:MOON RIVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-977-6866
Mailing Address - Street 1:790 OAK TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7502
Mailing Address - Country:US
Mailing Address - Phone:770-977-6866
Mailing Address - Fax:770-783-8639
Practice Address - Street 1:2000 FIRST DR
Practice Address - Street 2:SUITE 340
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7739
Practice Address - Country:US
Practice Address - Phone:770-977-6866
Practice Address - Fax:770-783-8639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA223654765AMedicaid