Provider Demographics
NPI:1700338365
Name:MEDLEAF LLC
Entity Type:Organization
Organization Name:MEDLEAF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-850-4058
Mailing Address - Street 1:13306 TUCKAWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1104
Mailing Address - Country:US
Mailing Address - Phone:703-850-4058
Mailing Address - Fax:
Practice Address - Street 1:13306 TUCKAWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1104
Practice Address - Country:US
Practice Address - Phone:703-850-4058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health