Healthcare Provider Details

I. General information

NPI: 1124806252
Provider Name (Legal Business Name): LUMINOUS HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 S FAIRFAX AVE
LOS ANGELES CA
90019-4401
US

IV. Provider business mailing address

1086 S FAIRFAX AVE
LOS ANGELES CA
90019-4401
US

V. Phone/Fax

Practice location:
  • Phone: 310-818-3476
  • Fax: 310-818-3476
Mailing address:
  • Phone: 310-818-3476
  • Fax: 310-818-3476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL JACOB GHODS
Title or Position: CEO
Credential: MD
Phone: 310-430-4513