Provider Demographics
NPI:1659611499
Name:LEAP OF FAITH COMMUNITY OUTREACH LLC
Entity Type:Organization
Organization Name:LEAP OF FAITH COMMUNITY OUTREACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMARIO
Authorized Official - Middle Name:D
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-612-4093
Mailing Address - Street 1:1458 INDIAN FOREST CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-5436
Mailing Address - Country:US
Mailing Address - Phone:404-288-7266
Mailing Address - Fax:
Practice Address - Street 1:1755 THE EXCHANGE SE
Practice Address - Street 2:SUITE 138
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-7400
Practice Address - Country:US
Practice Address - Phone:770-952-9272
Practice Address - Fax:770-952-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health