Provider Demographics
NPI:1003418369
Name:LUMINA LLC
Entity Type:Organization
Organization Name:LUMINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-283-3460
Mailing Address - Street 1:PO BOX 9868
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-5868
Mailing Address - Country:US
Mailing Address - Phone:510-283-3460
Mailing Address - Fax:
Practice Address - Street 1:353 ROUTE 10 STE 101
Practice Address - Street 2:
Practice Address - City:MANGILAO
Practice Address - State:GU
Practice Address - Zip Code:96913-1392
Practice Address - Country:US
Practice Address - Phone:671-969-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-12
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental