1275119869 NPI number — LEGACY HEALING AND TREATMENT NEW JERSEY LLC

Table of content: (NPI 1275119869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275119869 NPI number — LEGACY HEALING AND TREATMENT NEW JERSEY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY HEALING AND TREATMENT NEW JERSEY LLC
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1275119869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2960 N STATE ROAD 7 STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARGATE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33063-5756
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:
800 KINGS HWY N STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08034-1585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-267-5656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
DAMARIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
561-308-0865

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3245S0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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