MEDICARE: NEW LEAF FLORIDA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center		FL

General Provider Information

NPI Number	:	1063861284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LEAF FLORIDA LLC

Provider Business Mailing Address
First Line	:	PO BOX 743151
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3151
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4828 LAKE WORTH RD
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33463-3456
Country	:	US
Telephone Number	:	908-400-8606
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	NICOLA RAJARAM
Credential	:
Telephone Number	:	954-272-6723

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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Directions to “NEW LEAF FLORIDA LLC ” Practice Location

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