Provider Demographics
NPI:1619625878
Name:GREENLEAF, GARY (LAC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GREENLEAF
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 OAKS DR APT 210
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CATASAUQUA
Practice Address - State:PA
Practice Address - Zip Code:18032-2506
Practice Address - Country:US
Practice Address - Phone:610-264-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4235171100000X
PAOM000309171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist