Provider Demographics
NPI:1801351291
Name:MOONLIGHT DIAGNOSTICS LLC
Entity type:Organization
Organization Name:MOONLIGHT DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LIPSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-554-7798
Mailing Address - Street 1:3188 PARLIAMENT CIR STE 802
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-7271
Mailing Address - Country:US
Mailing Address - Phone:334-416-8298
Mailing Address - Fax:833-260-4473
Practice Address - Street 1:3188 PARLIAMENT CIR STE 802
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-7271
Practice Address - Country:US
Practice Address - Phone:334-416-8298
Practice Address - Fax:833-260-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-10
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty