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General NPI Number Information
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NPI Number | 1427435304
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Entity Type | Organization
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Legal Business Name | LUMINOUS DERMATOLOGY
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Dates
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Enumeration Date | 04/30/2015
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Last Update Date | 09/03/2015
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Provider Practice Location Address
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Address Line | 504 W PUEBLO ST STE 203
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City | SANTA BARBARA
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State | CA
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Zip | 93105-6211
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Country | US
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Telephone | 805-682-3329
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Fax | 805-682-3338
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Provider Business Mailing Address
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Address Line | 504 W PUEBLO ST STE 202
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City | SANTA BARBARA
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State | CA
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Zip | 93105-6211
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Country | US
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Telephone | 805-682-3329
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Fax | 805-682-3338
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRYAN GAMMON
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Credential | MD
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Telephone | 805-682-3329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | A118101
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License Number State | CA
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