=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881260073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENLEAF LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2021
-----------------------------------------------------
Last Update Date | 05/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5323 MACQUARIE POINT LN
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-4795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-825-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5323 MACQUARIE POINT LN
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-4795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-825-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. NKOLI O ILOANYA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-825-6297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------