Provider Demographics
NPI:1396547667
Name:LUMINOUS ORIGINS THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:LUMINOUS ORIGINS THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-443-7620
Mailing Address - Street 1:11310 134TH AVE N
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:55327-9741
Mailing Address - Country:US
Mailing Address - Phone:763-443-7620
Mailing Address - Fax:
Practice Address - Street 1:11310 134TH AVE N
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:MN
Practice Address - Zip Code:55327-9741
Practice Address - Country:US
Practice Address - Phone:763-443-7620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)