1003699752 NPI number — LEGACY HEALING CENTER CALIFORNIA LLC

Table of content: (NPI 1003699752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003699752 NPI number — LEGACY HEALING CENTER CALIFORNIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY HEALING CENTER CALIFORNIA 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003699752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-308-0865
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6519 CLEON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91606-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-808-4570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2023

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

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





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