=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699444380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMINOUS MIND MEDICINE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2021
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 30TH ST STE 502
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-480-8521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 30TH ST STE 502
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RN-COORDINATOR
-----------------------------------------------------
Name | VIOLETA REYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-480-8521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------