Healthcare Provider Details

I. General information

NPI: 1649992595
Provider Name (Legal Business Name): LUMINO VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 RIVERY BLVD STE 2005
GEORGETOWN TX
78628-3064
US

IV. Provider business mailing address

1500 RIVERY BLVD STE 2005
GEORGETOWN TX
78628-3064
US

V. Phone/Fax

Practice location:
  • Phone: 512-686-3424
  • Fax:
Mailing address:
  • Phone: 512-686-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WOOD
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 512-686-3424