Provider Demographics
NPI:1114450061
Name:LOTUS WELLNESS CENTER P.C.
Entity Type:Organization
Organization Name:LOTUS WELLNESS CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:GERDOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-988-5364
Mailing Address - Street 1:638 DUNSTEN CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1292 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067
Practice Address - Country:US
Practice Address - Phone:773-592-7227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009919101YM0800X
IL038011689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty