Healthcare Provider Details

I. General information

NPI: 1144650987
Provider Name (Legal Business Name): NEW LEAF CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15988B E. CHESTNUT ST.
MOUNT EATON OH
44659-0998
US

IV. Provider business mailing address

PO BOX 336 15988B E. CHESTNUT STREET
MOUNT EATON OH
44659-0336
US

V. Phone/Fax

Practice location:
  • Phone: 330-359-9888
  • Fax: 330-359-9890
Mailing address:
  • Phone: 330-359-9888
  • Fax: 330-359-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. OLIVIA K WENGER
Title or Position: EXECUTIVE DIRECTOR, PHYSICIAN
Credential: MD
Phone: 330-359-9888