Healthcare Provider Details

I. General information

NPI: 1639081029
Provider Name (Legal Business Name): CP LEADERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 STANLEY RD
FAYETTEVILLE GA
30214-1102
US

IV. Provider business mailing address

134 STANLEY RD
FAYETTEVILLE GA
30214-1102
US

V. Phone/Fax

Practice location:
  • Phone: 786-239-2698
  • Fax:
Mailing address:
  • Phone: 786-239-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: CARROLL PHILLIPS
Title or Position: PRESIDENT
Credential:
Phone: 786-239-2698