Provider Demographics
NPI:1962712117
Name:LUNA HEALTHCARE LLC
Entity type:Organization
Organization Name:LUNA HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-358-0956
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-0350
Mailing Address - Country:US
Mailing Address - Phone:425-358-0956
Mailing Address - Fax:877-481-6931
Practice Address - Street 1:2100 NE BROADWAY ST
Practice Address - Street 2:STE 305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1569
Practice Address - Country:US
Practice Address - Phone:503-236-3368
Practice Address - Fax:503-236-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500663828Medicaid
OR500663828Medicaid