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General NPI Number Information
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NPI Number | 1316369911
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Entity Type | Organization
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Legal Business Name | NEW LEAF MEDICAL, PLLC
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Dates
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Enumeration Date | 01/16/2014
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Last Update Date | 01/16/2014
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Provider Practice Location Address
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Address Line | 3622 COUNTY ROAD 101 S
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City | WAYZATA
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State | MN
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Zip | 55391-3424
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Country | US
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Telephone | 952-777-2355
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Fax |
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Provider Business Mailing Address
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Address Line | 3622 COUNTY ROAD 101 S
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City | WAYZATA
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State | MN
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Zip | 55391-3424
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Country | US
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Telephone | 952-777-2355
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Fax |
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Authorized Official
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Title or Position | SOLE SHAREHOLDER
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Name | SANDRA KAY WIITA
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Credential | MD
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Telephone | 952-777-2355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 42376
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License Number State | MN
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