Provider Demographics
NPI:1477280576
Name:LOTUSOM, LLC
Entity Type:Organization
Organization Name:LOTUSOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CRISTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MENZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-696-0910
Mailing Address - Street 1:1100 HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY FORD
Mailing Address - State:CO
Mailing Address - Zip Code:81067-2421
Mailing Address - Country:US
Mailing Address - Phone:719-696-0910
Mailing Address - Fax:719-316-2753
Practice Address - Street 1:408 N MAIN ST STE F
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067-1256
Practice Address - Country:US
Practice Address - Phone:719-423-8834
Practice Address - Fax:719-316-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14671305OtherCAQH