Provider Demographics
NPI:1336735950
Name:LA LUNA CENTER, LLC
Entity Type:Organization
Organization Name:LA LUNA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-470-3345
Mailing Address - Street 1:2020 CARIBOU DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4352
Mailing Address - Country:US
Mailing Address - Phone:970-282-8282
Mailing Address - Fax:303-200-7098
Practice Address - Street 1:2020 CARIBOU DR STE 201
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4352
Practice Address - Country:US
Practice Address - Phone:970-282-8282
Practice Address - Fax:303-200-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty