=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477280576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUSOM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2022
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 N MAIN ST STE F
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-423-8834
-----------------------------------------------------
Fax | 719-316-2753
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 HOPKINS AVE
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-696-0910
-----------------------------------------------------
Fax | 719-316-2753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PROVIDER
-----------------------------------------------------
Name | CRISTON MENZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 719-696-0910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------