Provider Demographics
NPI:1619339090
Name:LUNA LIVING BRAIN ENERGY SPA, LLC
Entity Type:Organization
Organization Name:LUNA LIVING BRAIN ENERGY SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-703-0941
Mailing Address - Street 1:8535 TANGLEWOOD SQ STE T10
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-6433
Mailing Address - Country:US
Mailing Address - Phone:440-703-0940
Mailing Address - Fax:
Practice Address - Street 1:8535 TANGLEWOOD SQ STE T10
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-6433
Practice Address - Country:US
Practice Address - Phone:440-703-0940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder