Provider Demographics
NPI:1699444380
Name:LUMINOUS MIND MEDICINE INC.
Entity type:Organization
Organization Name:LUMINOUS MIND MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN-COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIOLETA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-480-8521
Mailing Address - Street 1:411 30TH ST STE 502
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 30TH ST STE 502
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3300
Practice Address - Country:US
Practice Address - Phone:510-480-8521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-07
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty