Provider Demographics
NPI:1629492814
Name:A NEW LEAF, INC
Entity Type:Organization
Organization Name:A NEW LEAF, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CROWNOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-695-6355
Mailing Address - Street 1:2428 N STOKESBERRY PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5035
Mailing Address - Country:US
Mailing Address - Phone:208-695-6355
Mailing Address - Fax:208-939-5599
Practice Address - Street 1:2548 N STOKESBERRY PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1144
Practice Address - Country:US
Practice Address - Phone:208-695-6355
Practice Address - Fax:208-939-5599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A NEW LEAF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-10801041C0700X
IDM11819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1114063344Medicaid
ID1369080Medicare UPIN