1053758102 NPI number — LEGACY TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053758102 NPI number — LEGACY TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY TREATMENT CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053758102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4421 STUART ANDREW BLVD
Provider Second Line Business Mailing Address:
SUITE 608
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-1589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4421 STUART ANDREW BLVD
Provider Second Line Business Practice Location Address:
SUITE 608
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28217-1589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-715-9288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
IACULLO
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING DIRECTOR
Authorized Official Telephone Number:
561-715-9288

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130037 . This is a "NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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