MEDICARE: LEGACY ADVANCED HEALTH LLC

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	208D00000X	General Practice Physician		FL

General Provider Information

NPI Number	:	1538651112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY ADVANCED HEALTH LLC

Provider Business Mailing Address
First Line	:	15084 WILDWOOD CIR
Second Line	:
City	:	WESTLAKE
State	:	FL
Zip	:	33470-5435
Country	:	US
Telephone Number	:	772-333-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 N UNIVERSITY DR STE 120
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-6084
Country	:	US
Telephone Number	:	954-999-4881
Fax Number	:	772-303-3476

Authorized Official
Title or Position	:	AGNP
Name	:	PAMELA MANNING
Credential	:	NP
Telephone Number	:	954-999-4881

Provider Enumeration Date	:	05/31/2018
Last Update Date	:	12/26/2025

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