Provider Demographics
NPI:1811906944
Name:MODIMOON ENTERPRISES, LLC
Entity type:Organization
Organization Name:MODIMOON ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-781-9711
Mailing Address - Street 1:3915 WATSON RD
Mailing Address - Street 2:STE. LL2
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1251
Mailing Address - Country:US
Mailing Address - Phone:314-781-9711
Mailing Address - Fax:
Practice Address - Street 1:3915 WATSON RD
Practice Address - Street 2:STE. LL2
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-781-9711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONA261QR0206X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000000015183OtherESSENCE
MO194033OtherBCBS
MO7363390OtherCIGNA
MO194033OtherBCBS
MO000000015183OtherESSENCE