Healthcare Provider Details

I. General information

NPI: 1336940717
Provider Name (Legal Business Name): LEGACY TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 LAKE AVE STE 24
FORT WAYNE IN
46805-5428
US

IV. Provider business mailing address

3030 LAKE AVE STE 24
FORT WAYNE IN
46805-5428
US

V. Phone/Fax

Practice location:
  • Phone: 260-705-4587
  • Fax:
Mailing address:
  • Phone: 260-705-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ABDUL BARRIE
Title or Position: CEO
Credential:
Phone: 260-201-3119