Healthcare Provider Details

I. General information

NPI: 1528501178
Provider Name (Legal Business Name): LEGACY HEALHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 WOODMONT AVE
WINTER HAVEN FL
33884-3800
US

IV. Provider business mailing address

3050 WOODMONT AVE
WINTER HAVEN FL
33884-3800
US

V. Phone/Fax

Practice location:
  • Phone: 863-875-6584
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 04827
License Number StateFL

VIII. Authorized Official

Name: ROSE CARTER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 919-327-9674