Basic Information
| Provider Information | |||||||||
| NPI: | 1871073387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARCUS WELLNESS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LUMINOUS VITALITY BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RANDALL RD UNIT 1046 | ||||||||
| Address2: | |||||||||
| City: | WRENTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020937052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178413620 | ||||||||
| FaxNumber: | 6173345505 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NORWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020623487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817694006 | ||||||||
| FaxNumber: | 6175816040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2018 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6178413620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 245984 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.