Healthcare Provider Details

I. General information

NPI: 1326200056
Provider Name (Legal Business Name): GOLD LEAF ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 GREENWAY DR SUITE B5
JACKSON MO
63755-2913
US

IV. Provider business mailing address

1166 GREENWAY DR SUITE B5
JACKSON MO
63755-2913
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-9900
  • Fax: 573-243-5320
Mailing address:
  • Phone: 573-243-9900
  • Fax: 573-243-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number214985
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number1706830
License Number StateMO

VIII. Authorized Official

Name: MRS. SHERRI GAIL COOMER
Title or Position: PRESIDENT
Credential:
Phone: 573-243-9900