MEDICARE: LOTUS CARE MN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1881436483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOTUS CARE MN LLC

Provider Business Mailing Address
First Line	:	2915 WAYZATA BLVD STE 306
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2145
Country	:	US
Telephone Number	:	651-421-5221
Fax Number	:

Provider Business Practice Location Address
First Line	:	2915 WAYZATA BLVD STE 306
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2145
Country	:	US
Telephone Number	:	651-421-5221
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AYANTU SHANKULIE
Credential	:
Telephone Number	:	651-421-5221

Provider Enumeration Date	:	06/12/2024
Last Update Date	:	06/12/2024

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