Healthcare Provider Details

I. General information

NPI: 1861674350
Provider Name (Legal Business Name): GOLD LEAF ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 GREENWAY DR STE B5
JACKSON MO
63755-2921
US

IV. Provider business mailing address

1166 GREENWAY DR STE B5
JACKSON MO
63755-2921
US

V. Phone/Fax

Practice location:
  • Phone: 573-866-9900
  • Fax:
Mailing address:
  • Phone: 573-866-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateMO

VIII. Authorized Official

Name: MS. SHERRI G COOMER
Title or Position: PRESIDENT
Credential:
Phone: 573-243-9900