Organization
MOONLIGHT SUPPORT SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ABDIRAZAQ IBRAHIM (OWNER)
(602) 323-4873
Entity
Organization
Contact information
Practice address
3110 OLD HWY 8, 206, ROSEVILLE, MN 55113-5511
(602) 323-4873
Mailing address
5913 PLEASANT AVE STE 104, MINNEAPOLIS, MN 55419-2357
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Enumeration date
02/19/2020
Last updated
02/19/2020
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