Healthcare Provider Details

I. General information

NPI: 1801605829
Provider Name (Legal Business Name): LIQUID LOTUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14109 RIDGEWATER WAY
CHARLOTTE NC
28278-7020
US

IV. Provider business mailing address

2764 PLEASANT RD STE A UNIT 10103
FORT MILL SC
29708-7214
US

V. Phone/Fax

Practice location:
  • Phone: 917-270-0391
  • Fax:
Mailing address:
  • Phone: 917-270-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: KERI ALFORD
Title or Position: OWNER/ MANAGER
Credential:
Phone: 917-270-0391