Provider Demographics
NPI:1366238578
Name:MOONLIGHT MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:MOONLIGHT MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:CODIE
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-207-4335
Mailing Address - Street 1:3556 TUNDRA SWAN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-3501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3556 TUNDRA SWAN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-3501
Practice Address - Country:US
Practice Address - Phone:725-207-4335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty