Basic Information
Provider Information | |||||||||
NPI: | 1265740708 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUNA HEALTHCARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LUNA FAMILY HEARING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 350 | ||||||||
Address2: |   | ||||||||
City: | MAPLE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 980380350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253580956 | ||||||||
FaxNumber: | 8774816931 | ||||||||
Practice Location | |||||||||
Address1: | 21920 76TH AVE W | ||||||||
Address2: | SUITE 103 | ||||||||
City: | EDMONDS | ||||||||
State: | WA | ||||||||
PostalCode: | 980267980 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257440891 | ||||||||
FaxNumber: | 4257754449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2010 | ||||||||
LastUpdateDate: | 08/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUNA | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4253580956 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   | 231H00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   | 237600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
ID Information
ID | Type | State | Issuer | Description | 2010338 | 05 | WA |   | MEDICAID |