Healthcare Provider Details

I. General information

NPI: 1841108347
Provider Name (Legal Business Name): LEGACY HEALTHCARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 W MOONLIGHT MINE RD
POCATELLO ID
83201-9013
US

IV. Provider business mailing address

66 W FLAGLER ST STE 900
MIAMI FL
33130-1807
US

V. Phone/Fax

Practice location:
  • Phone: 954-548-7312
  • Fax: 954-548-7312
Mailing address:
  • Phone: 954-548-7312
  • Fax: 954-548-7312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. EVERTON ANTHONY BOOTHE
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 954-548-7312