Provider Demographics
NPI:1851189260
Name:GLOWTOX STUDIO LLC
Entity type:Organization
Organization Name:GLOWTOX STUDIO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:MORERA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:305-979-7195
Mailing Address - Street 1:1914 SW NOTRE DAME AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2469
Mailing Address - Country:US
Mailing Address - Phone:305-979-7195
Mailing Address - Fax:305-979-7195
Practice Address - Street 1:1914 SW NOTRE DAME AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2469
Practice Address - Country:US
Practice Address - Phone:305-979-7195
Practice Address - Fax:305-979-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-26
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14440985OtherCAQH
FL102375000Medicaid