National Provider Identifier Database

MOONLIGHT MOUNTAIN RECOVERY INC
Substance Abuse Disorder 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.


Contact Information

MOONLIGHT MOUNTAIN RECOVERY, INC
5230 W MOONLIGHT MINE RD
POCATELLO, ID83201-9013
Phone: 208-505-9990
Fax:
Website:
Specialty Taxonomy Code
* Substance Abuse Disorder Rehabilitation Facility 324500000X
Adult Mental Health 261QM0850X
Mental Health (Including Community Mental Health Center) 261QM0801X
Rehabilitation, Substance Use Disorder 261QR0405X

* Indicates primary specialty

NPI Profile & details for MOONLIGHT MOUNTAIN RECOVERY, INC

NPI Number 1861983413
Legal business name
LBN
MOONLIGHT MOUNTAIN RECOVERY, INC
Authorized official WADE MORDEN - (OWNER)
Entity Organization
Organization subpart No
Enumeration date 05/18/2018
Last updated 01/13/2021 - About 5 years ago
Sole proprietor1 Not specified
Identifiers
  • ID License #: 1
  • ID Other: 1 CERTIFICATE OF APPROVAL

1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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