Provider Demographics
NPI:1467066639
Name:LUMINOUS CARE, LLC
Entity Type:Organization
Organization Name:LUMINOUS CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON-SABOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-354-6988
Mailing Address - Street 1:1132 LIBERTY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-9377
Mailing Address - Country:US
Mailing Address - Phone:404-354-6988
Mailing Address - Fax:
Practice Address - Street 1:285 BOULEVARD NE STE 145
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4204
Practice Address - Country:US
Practice Address - Phone:844-884-9691
Practice Address - Fax:404-907-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000899643Medicaid