Healthcare Provider Details

I. General information

NPI: 1497362180
Provider Name (Legal Business Name): NEW LEAF NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2020
Last Update Date: 09/26/2020
Certification Date: 09/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W INDUSTRIAL DR
O FALLON MO
63366-1926
US

IV. Provider business mailing address

72 FREYMUTH RD
LAKE SAINT LOUIS MO
63367-1906
US

V. Phone/Fax

Practice location:
  • Phone: 314-626-3472
  • Fax:
Mailing address:
  • Phone: 314-322-8407
  • Fax: 314-499-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYMAN
Title or Position: OWNER
Credential: RD
Phone: 314-322-8407