Provider Demographics
NPI:1174124820
Name:MOONLIGHT HEALTHCARE SERIES LLC
Entity type:Organization
Organization Name:MOONLIGHT HEALTHCARE SERIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUSEGUN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ABEJIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-733-8622
Mailing Address - Street 1:3700 GRIFBRICK DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-1514
Mailing Address - Country:US
Mailing Address - Phone:469-733-8622
Mailing Address - Fax:469-965-9401
Practice Address - Street 1:3700 GRIFBRICK DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-1514
Practice Address - Country:US
Practice Address - Phone:469-733-8622
Practice Address - Fax:469-965-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care