=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790203420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7523 SOLANO ST
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92009-7529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-525-0599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7523 SOLANO ST
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92009-7529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-525-0599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CEO
-----------------------------------------------------
Name | JAIME A GOLDMAN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 202-525-0599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 293009
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------