Healthcare Provider Details

I. General information

NPI: 1053148643
Provider Name (Legal Business Name): LUNA MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10815 W MCDOWELL RD
AVONDALE AZ
85392-5007
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 209-956-7732
  • Fax:
Mailing address:
  • Phone: 209-956-7732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELO LICIAGA
Title or Position: CONSULTANT
Credential:
Phone: 480-200-0726