=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043750334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNARIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2017
-----------------------------------------------------
Last Update Date | 03/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 W WARNER RD SUITE 104
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-206-6199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 E FRIESS DR
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85022-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-206-6199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. NEAL ROBERT GOODRICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-206-6199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------