Healthcare Provider Details

I. General information

NPI: 1790608313
Provider Name (Legal Business Name): LEGACY INTEGRATED HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 VAN TEYLINGEN DR STE G
COLORADO SPRINGS CO
80917-4872
US

IV. Provider business mailing address

3585 VAN TEYLINGEN DR STE G
COLORADO SPRINGS CO
80917-4872
US

V. Phone/Fax

Practice location:
  • Phone: 719-649-9345
  • Fax:
Mailing address:
  • Phone: 719-649-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEMETRA SERIKI
Title or Position: PROVIDER/ADMINISTRATOR
Credential: APRN
Phone: 719-649-9345