Healthcare Provider Details

I. General information

NPI: 1942895792
Provider Name (Legal Business Name): LEGACY COMMUNITY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10211 W SAMPLE RD STE 212214
CORAL SPRINGS FL
33065-3972
US

IV. Provider business mailing address

10211 W SAMPLE RD STE 212214
CORAL SPRINGS FL
33065-3972
US

V. Phone/Fax

Practice location:
  • Phone: 954-603-7177
  • Fax: 786-364-7543
Mailing address:
  • Phone: 954-603-7177
  • Fax: 786-364-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LISSETTE GARZON
Title or Position: CEO
Credential: BS, CBHCMS, CTP
Phone: 954-600-1728