Provider Demographics
NPI:1568353449
Name:LUMOS ADVANCED TREATMENT CENTER INC
Entity type:Organization
Organization Name:LUMOS ADVANCED TREATMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-203-0000
Mailing Address - Street 1:16320 ALEXANDER CT
Mailing Address - Street 2:
Mailing Address - City:MONTE SERENO
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5204
Mailing Address - Country:US
Mailing Address - Phone:415-741-6103
Mailing Address - Fax:
Practice Address - Street 1:2516 SAMARITAN DR STE D
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:415-741-6103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-10
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty