Healthcare Provider Details

I. General information

NPI: 1245604883
Provider Name (Legal Business Name): GREEN LEAF AND ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 WHITEWOOD AVE
SPRING HILL FL
34609-5061
US

IV. Provider business mailing address

8100 WPA RD
BROOKSVILLE FL
34601-7056
US

V. Phone/Fax

Practice location:
  • Phone: 352-683-8630
  • Fax: 352-683-8630
Mailing address:
  • Phone: 248-343-1695
  • Fax: 352-684-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number11785
License Number StateFL

VIII. Authorized Official

Name: ONGELIA MOORE
Title or Position: MANAGER
Credential:
Phone: 248-343-1695