=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548811805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS FAMILY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50618 CHARLES ST
-----------------------------------------------------
City | OSSEO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54758-7508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-530-4080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 321
-----------------------------------------------------
City | OSSEO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54758-0321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-530-4080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. COURTNEY MARIE KLOES
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 715-530-4080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------