Healthcare Provider Details

I. General information

NPI: 1619339090
Provider Name (Legal Business Name): LUNA LIVING BRAIN ENERGY SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8535 TANGLEWOOD SQ STE T10
CHAGRIN FALLS OH
44023-6433
US

IV. Provider business mailing address

8535 TANGLEWOOD SQ STE T10
CHAGRIN FALLS OH
44023-6433
US

V. Phone/Fax

Practice location:
  • Phone: 440-703-0940
  • Fax:
Mailing address:
  • Phone: 440-703-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. WENDY KOMAC
Title or Position: CEO
Credential:
Phone: 440-703-0941