Healthcare Provider Details

I. General information

NPI: 1750689253
Provider Name (Legal Business Name): LEAP OF FAITH FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8420 STRIDER DR
CHARLOTTE NC
28212-1555
US

IV. Provider business mailing address

8420 STRIDER DR
CHARLOTTE NC
28212-1555
US

V. Phone/Fax

Practice location:
  • Phone: 980-200-3598
  • Fax:
Mailing address:
  • Phone: 980-200-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MANITA YVETTE JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 980-200-3598