=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871318428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEANFITRX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2024
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 S 4TH ST STE 209
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89101-6845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-599-0353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 FRENCHMENS KY
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-8621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-599-0353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP/OWNER
-----------------------------------------------------
Name | SHELDON SCOTT BRADLEY
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 251-599-0353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------