Provider Demographics
NPI:1073744504
Name:LUNA, LISA GABRIELA (CPO)
Entity Type:Individual
Prefix:PROF
First Name:LISA
Middle Name:GABRIELA
Last Name:LUNA
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16520 HARBOR BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1360
Mailing Address - Country:US
Mailing Address - Phone:714-210-1298
Mailing Address - Fax:714-210-1336
Practice Address - Street 1:16520 HARBOR BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1360
Practice Address - Country:US
Practice Address - Phone:714-210-1298
Practice Address - Fax:714-210-1336
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO02051222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200115OtherCMS NUMBER