Provider Demographics
NPI:1922815778
Name:MYLOTUS VILLAGE LLC
Entity type:Organization
Organization Name:MYLOTUS VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAMIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-732-4362
Mailing Address - Street 1:36 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-3545
Mailing Address - Country:US
Mailing Address - Phone:757-732-4362
Mailing Address - Fax:
Practice Address - Street 1:36 BROOKFIELD DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3545
Practice Address - Country:US
Practice Address - Phone:757-732-4362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services