Provider Demographics
NPI:1043027964
Name:MOONAH INC
Entity type:Organization
Organization Name:MOONAH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO -FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-223-2212
Mailing Address - Street 1:82 GRISWOLD DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1146
Mailing Address - Country:US
Mailing Address - Phone:251-223-2212
Mailing Address - Fax:
Practice Address - Street 1:82 GRISWOLD DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-3549
Practice Address - Country:US
Practice Address - Phone:302-267-4679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-13
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization