1710930771 NPI number — LEGACY HEALTHCARE INC

Table of content: (NPI 1710930771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710930771 NPI number — LEGACY HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY HEALTHCARE INC
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:
LEGACY PHYSICAL THERAPY & SPORTS TRAINING
Provider Other Organization Name Type Code:
3
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:
1710930771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34222-1156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-729-0003
Provider Business Mailing Address Fax Number:
941-729-0004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8175 US HIGHWAY 301 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARRISH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34219-8669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-729-0003
Provider Business Practice Location Address Fax Number:
941-729-0004
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHACON
Authorized Official First Name:
CESAR
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
941-302-9400

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 888322000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2989794 . This is a "AETNA GROUP PROV NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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