Healthcare Provider Details

I. General information

NPI: 1013392034
Provider Name (Legal Business Name): LEAP OF FAITH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NORTH WELLS STREET SUITE A
KOSCIUSKO MS
39090
US

IV. Provider business mailing address

115 NORTH WELLS STREET SUITE A
KOSCIUSKO MS
39090
US

V. Phone/Fax

Practice location:
  • Phone: 662-792-7746
  • Fax:
Mailing address:
  • Phone: 662-792-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. NATASHA N WINTERS
Title or Position: OWNER
Credential:
Phone: 662-792-7746