1902407034 NPI number — LOTUS RECOVERY CENTER LLC

Table of content: (NPI 1902407034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902407034 NPI number — LOTUS RECOVERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOTUS RECOVERY CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902407034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8413
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25303-0413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-928-5144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4202 MALDEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25306-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-928-5144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TOATH
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
304-928-5144

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1316593270 . This is a "JESSICA TOATH-CALLAHAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1902407034 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: DP00945150 . This is a "CHELSEA LEIGH CARTER LICSW" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com