Provider Demographics
NPI:1164035564
Name:THE LOTUS HAVEN PC
Entity Type:Organization
Organization Name:THE LOTUS HAVEN PC
Other - Org Name:THE LOTUS HAVEN PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYRONJALA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINEY- GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-944-1174
Mailing Address - Street 1:425 DUTCHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-7642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 DANNON VW SW STE 4101
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2159
Practice Address - Country:US
Practice Address - Phone:404-944-1174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care