=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457222655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAP HEALTH MSO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2025
-----------------------------------------------------
Last Update Date | 09/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 ROCKEFELLER PLZ FL 2
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10020-2089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-998-8932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3702 W SPRUCE ST # 1504
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33607-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | BRIAN WIGG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 929-998-9207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------