MEDICARE: PHILADELPHIA NEW LEAF 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

General Provider Information

NPI Number	:	1982010039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILADELPHIA NEW LEAF LLC

Provider Business Mailing Address
First Line	:	3600 MARKET ST
Second Line	:	SUITE 601
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2641
Country	:	US
Telephone Number	:	908-400-8606
Fax Number	:	908-928-9353

Provider Business Practice Location Address
First Line	:	3600 MARKET ST
Second Line	:	SUITE 601
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-2641
Country	:	US
Telephone Number	:	908-400-8606
Fax Number	:	908-928-9353

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. FRANK SILLETTI
Credential	:	LCADC
Telephone Number	:	908-400-8606

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	07/09/2014

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