Healthcare Provider Details

I. General information

NPI: 1114450061
Provider Name (Legal Business Name): LOTUS WELLNESS CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1292 W NORTHWEST HWY
PALATINE IL
60067
US

IV. Provider business mailing address

638 DUNSTEN CIR
NORTHBROOK IL
60062-2613
US

V. Phone/Fax

Practice location:
  • Phone: 773-592-7227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180009919
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011689
License Number StateIL

VIII. Authorized Official

Name: LEO GERDOV
Title or Position: OWNER
Credential: D.C.
Phone: 630-988-5364