Provider Demographics
NPI:1457961864
Name:DR. MOMA LLC
Entity Type:Organization
Organization Name:DR. MOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYLVIENASH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:719-646-9834
Mailing Address - Street 1:411 LAKEWOOD CIR STE B114
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-4629
Mailing Address - Country:US
Mailing Address - Phone:719-597-4768
Mailing Address - Fax:719-591-2309
Practice Address - Street 1:411 LAKEWOOD CIR STE B114
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-4629
Practice Address - Country:US
Practice Address - Phone:719-597-4768
Practice Address - Fax:719-591-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-31
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty