Provider Demographics
NPI:1780118992
Name:NEW LEAF NUTRITION LLC
Entity type:Organization
Organization Name:NEW LEAF NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RD
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-948-8810
Mailing Address - Street 1:5261 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4903
Mailing Address - Country:US
Mailing Address - Phone:206-948-8810
Mailing Address - Fax:
Practice Address - Street 1:5261 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4903
Practice Address - Country:US
Practice Address - Phone:206-948-8810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10150450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500703686Medicaid