Provider Demographics
NPI:1740237247
Name:LEATHER BANANA,INC
Entity type:Organization
Organization Name:LEATHER BANANA,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-254-0517
Mailing Address - Street 1:602 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6620
Mailing Address - Country:US
Mailing Address - Phone:574-254-0517
Mailing Address - Fax:574-254-0162
Practice Address - Street 1:602 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6620
Practice Address - Country:US
Practice Address - Phone:574-254-0517
Practice Address - Fax:574-254-0162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5651070001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5651070001Medicare NSC