Provider Demographics
NPI:1295092252
Name:MOONTOWER WELLNESS, LLC
Entity type:Organization
Organization Name:MOONTOWER WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:WEATHERBY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:512-522-7708
Mailing Address - Street 1:11705 AIRPORT WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-2710
Mailing Address - Country:US
Mailing Address - Phone:512-522-7708
Mailing Address - Fax:512-233-0824
Practice Address - Street 1:11705 AIRPORT WAY STE 205
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-2710
Practice Address - Country:US
Practice Address - Phone:512-522-7708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN60942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty