=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770373409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCENTRA WELLNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 TRAVIS STREET SUITE 210 PMB1656
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77002-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-314-0630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 TRAVIS STREET SUITE 210 PMB1656
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77002-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-314-0630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRANDON SIMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-315-5165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------