Organization
MOON RIVER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARIA TERESA SMITH PT (PRESIDENT)
(770) 977-6866
Entity
Organization
Contact information
Practice address
2000 FIRST DR, SUITE 340, MARIETTA, GA 30062-7739
(770) 977-6866
(770) 783-8639
Mailing address
790 OAK TRAIL DR, MARIETTA, GA 30062-7502
(770) 977-6866
(770) 783-8639
Taxonomy
Speciality
Code
Description
License number
State
252Y00000X
Early Intervention Provider Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
223654765A
—
GA
Enumeration date
11/05/2013
Last updated
11/05/2013
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