MEDICARE: LOTUS SPA & SALON, 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	225700000X	Massage Therapist
2	164X00000X	Licensed Vocational Nurse

General Provider Information

NPI Number	:	1922734482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOTUS SPA & SALON, LLC

Provider Business Mailing Address
First Line	:	6115 CAMP BOWIE BLVD STE 154
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5544
Country	:	US
Telephone Number	:	817-386-7865
Fax Number	:

Provider Business Practice Location Address
First Line	:	6115 CAMP BOWIE BLVD STE 154
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5544
Country	:	US
Telephone Number	:	817-386-7865
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	RUTH STOUT
Credential	:	LMT
Telephone Number	:	817-386-7865

Provider Enumeration Date	:	07/27/2022
Last Update Date	:	07/27/2022

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Directions to “LOTUS SPA & SALON, LLC ” Practice Location

Language	Start Address	Practice Location

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