MEDICARE: LEGACY MEDICAL CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)		IL

General Provider Information

NPI Number	:	1104375518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY MEDICAL CARE INC

Provider Business Mailing Address
First Line	:	1715 W ALGONQUIN RD
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-5401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 W ALGONQUIN RD
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-5401
Country	:	US
Telephone Number	:	847-749-2248
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. MELISSA DONORIO
Credential	:	RN
Telephone Number	:	847-749-2248

Provider Enumeration Date	:	09/26/2016
Last Update Date	:	09/26/2016

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