Basic Information
| Provider Information | |||||||||
| NPI: | 1851466700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUNA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | SERAPHIM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SOUTH JACKSON | ||||||||
| Address2: | STE 2 & 3 | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566304400 | ||||||||
| FaxNumber: | 9566304447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SOUTH JACKSON | ||||||||
| Address2: | STE 2 & 3 | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566304400 | ||||||||
| FaxNumber: | 9566304447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 06/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 110825 | TX | N | Other Service Providers | Specialist | 225X00000X | 110825 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 143404501 | 05 | TX | MEDICAID |