Provider Demographics
NPI:1871101162
Name:LUMINOSITY HEADQUARTERS
Entity type:Organization
Organization Name:LUMINOSITY HEADQUARTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-391-8120
Mailing Address - Street 1:108 N BEHREND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8418
Mailing Address - Country:US
Mailing Address - Phone:620-391-8120
Mailing Address - Fax:
Practice Address - Street 1:108 N BEHREND AVE STE E
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8418
Practice Address - Country:US
Practice Address - Phone:620-391-8120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-22
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health