Provider Demographics
NPI:1639543200
Name:GREEN LEAF AND COMPANY, LLC
Entity Type:Organization
Organization Name:GREEN LEAF AND COMPANY, LLC
Other - Org Name:THE PALMS ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ONGELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-343-1695
Mailing Address - Street 1:8100 WPA RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-7056
Mailing Address - Country:US
Mailing Address - Phone:248-343-1695
Mailing Address - Fax:352-684-4984
Practice Address - Street 1:7364 LAGOOD RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606
Practice Address - Country:US
Practice Address - Phone:352-684-4984
Practice Address - Fax:352-684-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11765305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service