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General NPI Number Information
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NPI Number | 1811754385
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Entity Type | Organization
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Legal Business Name | LUNA NUTRITION
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Dates
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Enumeration Date | 03/01/2024
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Last Update Date | 03/01/2024
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Provider Practice Location Address
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Address Line | 10850 LINCOLN TRAIL STE 16, #248
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City | FAIRVIEW HEIGHTS
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State | IL
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Zip | 62208
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Country | US
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Telephone | 615-579-2435
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Fax |
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Provider Business Mailing Address
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Address Line | 10850 LINCOLN TRAIL STE 16, #248
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City | FAIRVIEW HEIGHTS
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State | IL
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Zip | 62208
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Country | US
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Telephone | 615-579-2435
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMY KNOX
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Credential | CNS
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Telephone | 615-579-2435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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