Provider Demographics
NPI:1043785736
Name:LUNA MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:LUNA MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-821-0276
Mailing Address - Street 1:134 CHACHALACA
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-7962
Mailing Address - Country:US
Mailing Address - Phone:956-821-0276
Mailing Address - Fax:956-626-1511
Practice Address - Street 1:112 W QUEEN ISABELLA STE C
Practice Address - Street 2:
Practice Address - City:PORT ISABEL
Practice Address - State:TX
Practice Address - Zip Code:78578-2970
Practice Address - Country:US
Practice Address - Phone:956-821-0276
Practice Address - Fax:956-626-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty