Healthcare Provider Details

I. General information

NPI: 1033494372
Provider Name (Legal Business Name): LEAP ONE ENTERPRISE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5160 GALAXIE DR
JACKSON MS
39206-4308
US

IV. Provider business mailing address

5160 GALAXIE DR
JACKSON MS
39206-4308
US

V. Phone/Fax

Practice location:
  • Phone: 615-525-1019
  • Fax: 601-366-3415
Mailing address:
  • Phone: 615-525-1019
  • Fax: 601-366-3415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number21249
License Number StateMS

VIII. Authorized Official

Name: FOSTER LAGINA C
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 615-525-1019