Healthcare Provider Details

I. General information

NPI: 1790490480
Provider Name (Legal Business Name): LUNA HEALTHCARE PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14831 N FLORIDA AVE
TAMPA FL
33613-1825
US

IV. Provider business mailing address

3218 W HORATIO ST
TAMPA FL
33609-3028
US

V. Phone/Fax

Practice location:
  • Phone: 813-330-2737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: THEOPHILUS SAI
Title or Position: MEMBER
Credential:
Phone: 813-600-9981