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General NPI Number Information
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NPI Number | 1871101162
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Entity Type | Organization
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Legal Business Name | LUMINOSITY HEADQUARTERS
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 108 N BEHREND AVE STE E
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City | FARMINGTON
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State | NM
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Zip | 87401-8418
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Country | US
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Telephone | 620-391-8120
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Fax |
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Provider Business Mailing Address
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Address Line | 108 N BEHREND AVE STE E
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City | FARMINGTON
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State | NM
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Zip | 87401-8418
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Country | US
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Telephone | 620-391-8120
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | MR. LONNIE WHITAKER
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Credential |
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Telephone | 620-391-8120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1800X
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Taxonomy Name | Corporate Health Clinic/Center
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License Number |
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License Number State |
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