Healthcare Provider Details

I. General information

NPI: 1376291674
Provider Name (Legal Business Name): BLUE LOTUS HEALTHCARE HOLDING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20944 SHERMAN WAY STE 112
CANOGA PARK CA
91303-3629
US

IV. Provider business mailing address

3712 PASEO PRIMARIO
CALABASAS CA
91302-3054
US

V. Phone/Fax

Practice location:
  • Phone: 310-467-0661
  • Fax:
Mailing address:
  • Phone: 310-467-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MANDANA AMIN NAZAR
Title or Position: CEO
Credential:
Phone: 310-467-0661