Healthcare Provider Details

I. General information

NPI: 1811754385
Provider Name (Legal Business Name): LUNA NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 TOWER SQUARE PLZ STE 200
MARION IL
62959-2409
US

IV. Provider business mailing address

10850 LINCOLN TRAIL STE 16, #248
FAIRVIEW HEIGHTS IL
62208
US

V. Phone/Fax

Practice location:
  • Phone: 618-680-0319
  • Fax: 618-484-1900
Mailing address:
  • Phone: 615-579-2435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: AMY KNOX
Title or Position: OWNER
Credential: CNS
Phone: 615-579-2435