Provider Demographics
NPI:1942790555
Name:REMEMBER THE MOON, LLC
Entity Type:Organization
Organization Name:REMEMBER THE MOON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-521-3657
Mailing Address - Street 1:537 HAYDEN BRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1500
Mailing Address - Country:US
Mailing Address - Phone:541-521-3657
Mailing Address - Fax:
Practice Address - Street 1:207 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3008
Practice Address - Country:US
Practice Address - Phone:541-345-9204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Single Specialty