Healthcare Provider Details

I. General information

NPI: 1114836533
Provider Name (Legal Business Name): LEGACY MENTAL & WELLNESS HEALTH GROUP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 NW 114TH AVE UNIT 8
DORAL FL
33178-4372
US

IV. Provider business mailing address

4005 NW 114TH AVE UNIT 8
DORAL FL
33178-4372
US

V. Phone/Fax

Practice location:
  • Phone: 786-816-0908
  • Fax: 786-999-8805
Mailing address:
  • Phone: 786-816-0908
  • Fax: 786-999-8805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ERNESTO GUEVARA
Title or Position: OWNER
Credential: APRN
Phone: 786-816-0908