Healthcare Provider Details

I. General information

NPI: 1295339166
Provider Name (Legal Business Name): LOTUS MOON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 11/22/2020
Certification Date: 11/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14667 LAKE STREET EXT
MINNETONKA MN
55345-2926
US

IV. Provider business mailing address

15401 LAKE STREET EXT
MINNETONKA MN
55345-1914
US

V. Phone/Fax

Practice location:
  • Phone: 612-584-0917
  • Fax:
Mailing address:
  • Phone: 612-535-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: PESEY M KUOCH
Title or Position: OWNER
Credential:
Phone: 612-535-7292