Provider Demographics
NPI:1043482128
Name:LEIF O NORDBERG MD, LLC
Entity Type:Organization
Organization Name:LEIF O NORDBERG MD, LLC
Other - Org Name:CVW BODY DESIGN CENTER - STAMFORD, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:O
Authorized Official - Last Name:NORDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-324-1971
Mailing Address - Street 1:2001 W MAIN ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4501
Mailing Address - Country:US
Mailing Address - Phone:203-324-1971
Mailing Address - Fax:
Practice Address - Street 1:2001 W MAIN ST
Practice Address - Street 2:SUITE 155
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-324-4700
Practice Address - Fax:203-324-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT349261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT240000178OtherMEDICARE ID