=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245638063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA KATSUTRA WELLNESS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2014
-----------------------------------------------------
Last Update Date | 12/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9835 SW 72ND ST STE 208
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-381-5429
-----------------------------------------------------
Fax | 305-381-5542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9835 SW 72ND ST STE 208
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-381-5429
-----------------------------------------------------
Fax | 305-381-5542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID SANTIAGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-381-5429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | ME64467
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------