Provider Demographics
NPI:1073364170
Name:LUMINOSITY INTEGRATED REJUVENATION
Entity Type:Organization
Organization Name:LUMINOSITY INTEGRATED REJUVENATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-793-5077
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:STAFFORDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41256-0055
Mailing Address - Country:US
Mailing Address - Phone:606-793-5077
Mailing Address - Fax:
Practice Address - Street 1:503 DEPOT ROAD
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240
Practice Address - Country:US
Practice Address - Phone:606-793-5077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care