1336753722 NPI number — LEGACY OF N. FL.

Table of content: (NPI 1336753722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336753722 NPI number — LEGACY OF N. FL.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY OF N. FL.
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:
1336753722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1468 SW MAIN BLVD STE 105-5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32025-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-623-0561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 SW OAKWOOD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32024-0807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-623-0561
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MINTON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
DUANE
Authorized Official Title or Position:
OWNER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
386-623-0561

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109341000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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