MEDICARE: LUMIN ER CAMP BOWIE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0002X	Emergency Care Clinic/Center

General Provider Information

NPI Number	:	1730541475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMIN ER CAMP BOWIE LLC

Provider Business Mailing Address
First Line	:	4520 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3837
Country	:	US
Telephone Number	:	913-972-4976
Fax Number	:

Provider Business Practice Location Address
First Line	:	4520 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3837
Country	:	US
Telephone Number	:	913-972-4976
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JEFF VANHORN
Credential	:
Telephone Number	:	913-972-4976

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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