Healthcare Provider Details

I. General information

NPI: 1235183021
Provider Name (Legal Business Name): LEGACY HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 GULF OF MEXICO DR SUITE 209
LONGBOAT KEY FL
34228-2612
US

IV. Provider business mailing address

PO BOX 1156
ELLENTON FL
34222-1156
US

V. Phone/Fax

Practice location:
  • Phone: 941-383-0414
  • Fax: 941-383-0120
Mailing address:
  • Phone: 941-729-0003
  • Fax: 941-729-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CESAR CHACON
Title or Position: ADMINISTRATOR
Credential:
Phone: 941-302-9400