Healthcare Provider Details

I. General information

NPI: 1053815654
Provider Name (Legal Business Name): LEGACY OUTPATIENT THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11618 SOUTH ST UNIT 201
ARTESIA CA
90701
US

IV. Provider business mailing address

11618 SOUTH ST # 201
ARTESIA CA
90701-6618
US

V. Phone/Fax

Practice location:
  • Phone: 562-467-0777
  • Fax: 562-683-3047
Mailing address:
  • Phone: 562-467-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JILL RAIZA DELA CRUZ
Title or Position: CEO
Credential: BSN, RN, MSN, FNP-C
Phone: 562-467-0777