Provider Demographics
NPI:1609862606
Name:LOTUS PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:LOTUS PHYSICAL THERAPY INC
Other - Org Name:HEALTH ENHANCEMENT PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LITVINOV
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:310-494-1422
Mailing Address - Street 1:PO BOX 25595
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0595
Mailing Address - Country:US
Mailing Address - Phone:310-494-1422
Mailing Address - Fax:310-496-0868
Practice Address - Street 1:11710 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1503
Practice Address - Country:US
Practice Address - Phone:310-494-1422
Practice Address - Fax:310-496-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-25
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16643AMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER