Organization
MOONLIGHT MOUNTAIN RECOVERY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WADE MORDEN (OWNER)
(208) 505-9990
Entity
Organization
Contact information
Practice address
5230 W MOONLIGHT MINE RD, POCATELLO, ID 83201-9013
(208) 505-9990
Mailing address
2154 E 1340 S, HEBER CITY, UT 84032-1248
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
1
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1
CERTIFICATE OF APPROVAL
ID
Enumeration date
05/18/2018
Last updated
01/13/2021
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