=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821859000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WANDERING LOTUS HEALING ARTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2024
-----------------------------------------------------
Last Update Date | 01/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7340 GRACE DR STE A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-832-3269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3108 SPRING HOUSE CT
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21797-7541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LISA MARIE DESPRES
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 443-832-3269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------