=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700124179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS RECOVERY REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2013
-----------------------------------------------------
Last Update Date | 05/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 NW 17TH AVE SUITE F
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33445-2516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-588-4934
-----------------------------------------------------
Fax | 865-984-2426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 NE 5TH AVE D-117
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-5658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-588-4934
-----------------------------------------------------
Fax | 865-984-2426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | RENEE STIFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-588-7039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------