| Moonlight Support Services Llc | |
|
3110 Old Hwy 8 206 Roseville MN 55113-5511 | |
| (602) 323-4873 | |
| Not Available |
| Full Name | Moonlight Support Services Llc |
|---|---|
| Speciality | Clinic/center - Adolescent And Children Mental Health |
| Location | 3110 Old Hwy 8, Roseville, Minnesota |
| Authorized Official Name and Position | Abdirazaq Ibrahim (OWNER) |
| Authorized Official Contact | 6023234873 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Moonlight Support Services Llc 5913 Pleasant Ave Ste 104 Minneapolis MN 55419-2357 Ph: () - | Moonlight Support Services Llc 3110 Old Hwy 8 206 Roseville MN 55113-5511 Ph: (602) 323-4873 |
| NPI Number | 1164055026 |
|---|---|
| Provider Enumeration Date | 02/19/2020 |
| Last Update Date | 02/19/2020 |
| Certification Date | 02/19/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164055026 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0855X | Clinic/center - Adolescent And Children Mental Health | (* (Not Available)) | Primary |
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