Provider Demographics
NPI:1003159963
Name:LEAF IT UP MEDSPA,LLC
Entity Type:Organization
Organization Name:LEAF IT UP MEDSPA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IVEL
Authorized Official - Middle Name:CRISTINA
Authorized Official - Last Name:DE FREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-391-9869
Mailing Address - Street 1:1000 N BROADWALK STE 1
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-1221
Mailing Address - Country:US
Mailing Address - Phone:954-391-9869
Mailing Address - Fax:954-573-6505
Practice Address - Street 1:1000 N BROADWALK STE 1
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-1221
Practice Address - Country:US
Practice Address - Phone:954-391-9869
Practice Address - Fax:954-573-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty