Provider Demographics
NPI:1861597569
Name:MOON, JAMES HOWARD (RT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:HOWARD
Last Name:MOON
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1718
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-1679
Mailing Address - Country:US
Mailing Address - Phone:678-654-1560
Mailing Address - Fax:
Practice Address - Street 1:210 W STONE AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-5452
Practice Address - Country:US
Practice Address - Phone:678-654-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSCRQSA#00-85042471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography