MOONLIGHT MOUNTAIN RECOVERY INC NPI 1861983413

NPI Information

NPI: 1861983413
Provider Name: MOONLIGHT MOUNTAIN RECOVERY, INC
Classification: Substance Abuse Rehabilitation Facility - 324500000X
Entity Type: Organization

CLIA Number: 13D2179756

Address:
5230 W MOONLIGHT MINE RD
POCATELLO, ID
ZIP 83201
Phone: (208) 505-9990
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MOONLIGHT MOUNTAIN RECOVERY, INC is a substance abuse rehabilitation facility in Pocatello, ID. The provider is 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. MOONLIGHT MOUNTAIN RECOVERY, INC NPI is 1861983413. The provider is registered as an organization entity type.

The provider's business location address is:

5230 W MOONLIGHT MINE RD
POCATELLO, ID
ZIP 83201-013
Phone: (208) 505-9990

The provider's authorized official is Wade Morden .
The authorized official title is Owner and has the following contact phone number (208) 505-9990.

The CLIA number assigned to this NPI record is 13D2179756 - other with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 5/18/2018 and was last updated on 1/13/2021.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QM0801X	Clinic/Center	Mental Health (Including Community Mental Health Center)			No
2	261QM0850X	Clinic/Center	Adult Mental Health			No
3	261QR0405X	Clinic/Center	Rehabilitation, Substance Use Disorder			No
4	324500000X	Substance Abuse Rehabilitation Facility		1	IDAHO	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	1	OTHER	IDAHO	CERTIFICATE OF APPROVAL

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/14/2023

NPI Synchronization or Removal

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