Healthcare Provider Details

I. General information

NPI: 1902407034
Provider Name (Legal Business Name): LOTUS RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 MALDEN DR
MALDEN WV
25306-6442
US

IV. Provider business mailing address

PO BOX 8413
SOUTH CHARLESTON WV
25303-0413
US

V. Phone/Fax

Practice location:
  • Phone: 304-928-5144
  • Fax:
Mailing address:
  • Phone: 304-928-5144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSICA ANN TOATH
Title or Position: MEDICAL DIRECTOR
Credential: FNP-C
Phone: 304-928-5144