Provider Demographics
NPI:1083023501
Name:SHINING LEAF IPA, LLC
Entity Type:Organization
Organization Name:SHINING LEAF IPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:JENI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-269-4888
Mailing Address - Street 1:2900 BRAGG ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-1144
Mailing Address - Country:US
Mailing Address - Phone:718-268-4888
Mailing Address - Fax:
Practice Address - Street 1:2900 BRAGG ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-1144
Practice Address - Country:US
Practice Address - Phone:718-268-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health