Provider Demographics
NPI:1497186167
Name:LOTUS INTEGRATED LONGEVITY ANTI-AGING CENTER, INC.
Entity Type:Organization
Organization Name:LOTUS INTEGRATED LONGEVITY ANTI-AGING CENTER, INC.
Other - Org Name:L.I.L.A.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EPIFANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-772-4971
Mailing Address - Street 1:2301 E EVESHAM RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4501
Mailing Address - Country:US
Mailing Address - Phone:856-772-4971
Mailing Address - Fax:856-772-1140
Practice Address - Street 1:2301 E EVESHAM RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4501
Practice Address - Country:US
Practice Address - Phone:856-772-4971
Practice Address - Fax:856-772-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05996900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty