Provider Demographics
NPI:1033494372
Name:LEAP ONE ENTERPRISE PLLC
Entity type:Organization
Organization Name:LEAP ONE ENTERPRISE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FOSTER
Authorized Official - Middle Name:LAGINA
Authorized Official - Last Name:C
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-525-1019
Mailing Address - Street 1:5160 GALAXIE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4308
Mailing Address - Country:US
Mailing Address - Phone:615-525-1019
Mailing Address - Fax:601-366-3415
Practice Address - Street 1:5160 GALAXIE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4308
Practice Address - Country:US
Practice Address - Phone:615-525-1019
Practice Address - Fax:601-366-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21249207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty