Healthcare Provider Details

I. General information

NPI: 1235884388
Provider Name (Legal Business Name): DREAM LIFE LEGACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 W GRANADA BLVD STE 101
ORMOND BEACH FL
32174-5107
US

IV. Provider business mailing address

67 N ST ANDREWS DR
ORMOND BEACH FL
32174-3863
US

V. Phone/Fax

Practice location:
  • Phone: 386-985-2292
  • Fax:
Mailing address:
  • Phone: 513-604-5445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL WALTERS
Title or Position: PRESIDENT
Credential:
Phone: 513-604-5445