13D2179756 CLIA NUMBER - MOONLIGHT MOUNTAIN RECOVERY INC

Laboratory Demographics

CLIA Number: 13D2179756

Facility Name: MOONLIGHT MOUNTAIN RECOVERY INC

Facility Address:
5230 W MOONLIGHT MINE RD
POCATELLO, ID
ZIP 83201
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Facility Phone Number: 801 915-8542

Facility Type: Other - RESIDENTIAL TREATEMENT

Certificate Type: Waiver

NPI Number: 1861983413

Taxonomy: 324500000X - Substance Abuse Rehabilitation Facility
A facility or distinct part of a facility that provides a 24 hr therapeutically planned living and rehabilitative intervention environment for the treatment of individuals with disorders in the abuse of drugs, alcohol, and other substances.

CLIA Record

Field Name	Field Value
CLIA Number	13D2179756
LAB Type	Other - RESIDENTIAL TREATEMENT
Facility Name	MOONLIGHT MOUNTAIN RECOVERY INC
Street	5230 W MOONLIGHT MINE RD
City	POCATELLO
State	ID
ZIP	83201
Phone	801 915-8542
CertificateType	4
CertificateEffectiveDate	3/2/2024
CertificateExpirationDate	3/1/2026
FacilityType	Waiver

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This page was last updated on: 4/23/2024