Healthcare Provider Details

I. General information

NPI: 1003699752
Provider Name (Legal Business Name): LEGACY HEALING CENTER CALIFORNIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 CASTILIAN DR
LOS ANGELES CA
90068-2614
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 185
BOCA RATON FL
33431-4000
US

V. Phone/Fax

Practice location:
  • Phone: 561-308-0865
  • Fax:
Mailing address:
  • Phone: 561-308-0865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DAMARIS GONZALEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 561-308-0865