Healthcare Provider Details

I. General information

NPI: 1831640465
Provider Name (Legal Business Name): LUMINIS HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MERCANTILE LN SUITE 111
LARGO MD
20774-5376
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 301-925-7610
  • Fax: 301-925-7619
Mailing address:
  • Phone: 443-481-6476
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD02332
License Number StateMD

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: VICE PRESIDENT
Credential:
Phone: 443-481-6415