Healthcare Provider Details

I. General information

NPI: 1376318931
Provider Name (Legal Business Name): POWELL'S PRECIOUS LOTUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 REO AVE
SOUTH BEND IN
46619-1341
US

IV. Provider business mailing address

5316 REO AVE
SOUTH BEND IN
46619-1341
US

V. Phone/Fax

Practice location:
  • Phone: 574-440-1731
  • Fax:
Mailing address:
  • Phone: 574-387-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KIM POWELL
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 574-387-9160