Healthcare Provider Details

I. General information

NPI: 1669258067
Provider Name (Legal Business Name): BLU LOTUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 HUNTINGTON DR
GASTONIA NC
28056-8476
US

IV. Provider business mailing address

1819 SARDIS RD N STE 350
CHARLOTTE NC
28270-2472
US

V. Phone/Fax

Practice location:
  • Phone: 704-953-2825
  • Fax:
Mailing address:
  • Phone: 704-755-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHERRELL ERWIN
Title or Position: CEO
Credential: RN CCM
Phone: 704-953-2825