Basic Information
| Provider Information | |||||||||
| NPI: | 1790095941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUNA HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LUNA FAMILY HEARING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 350 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980380350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253580956 | ||||||||
| FaxNumber: | 8774816931 | ||||||||
| Practice Location | |||||||||
| Address1: | 11390 SE 82ND AVE | ||||||||
| Address2: | STE. 801 | ||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970867637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036535004 | ||||||||
| FaxNumber: | 5037940531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | LUNA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253580956 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 500663826 | 05 | OR | MEDICAID |