Healthcare Provider Details

I. General information

NPI: 1679253686
Provider Name (Legal Business Name): LUMNOVA HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 HUCKLEBERRY RD
CANTON GA
30114-2117
US

IV. Provider business mailing address

612 HUCKLEBERRY RD
CANTON GA
30114-2117
US

V. Phone/Fax

Practice location:
  • Phone: 404-576-8644
  • Fax: 470-408-3969
Mailing address:
  • Phone: 404-576-8644
  • Fax: 470-408-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID PATRICK LONG JR.
Title or Position: PARTNER
Credential:
Phone: 404-576-8644