MEDICARE: LUMINANCE HEALTH GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility		CA

General Provider Information

NPI Number	:	1306370192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMINANCE HEALTH GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 268866
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-8866
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24662 EL CAMINO CAPISTRANO
Second Line	:
City	:	DANA POINT
State	:	CA
Zip	:	92629-3012
Country	:	US
Telephone Number	:	949-482-8315
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL CASTANON
Credential	:
Telephone Number	:	310-303-8325

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	04/18/2017

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