Provider Demographics
NPI:1447532403
Name:LAVENDER LOTUS ACUPUNCTURE LLC
Entity type:Organization
Organization Name:LAVENDER LOTUS ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDIE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:ARMIJO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, MSOM, LAC
Authorized Official - Phone:608-213-2933
Mailing Address - Street 1:204 W COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9211
Mailing Address - Country:US
Mailing Address - Phone:608-213-2933
Mailing Address - Fax:
Practice Address - Street 1:130 GREGOR ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:WI
Practice Address - Zip Code:53594-1224
Practice Address - Country:US
Practice Address - Phone:608-213-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty