Healthcare Provider Details

I. General information

NPI: 1457298259
Provider Name (Legal Business Name): NEXTGEN LEGACY HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 GREENFIELD RD STE 300
DEARBORN MI
48120-1805
US

IV. Provider business mailing address

3200 GREENFIELD RD STE 300
DEARBORN MI
48120-1805
US

V. Phone/Fax

Practice location:
  • Phone: 312-256-5459
  • Fax:
Mailing address:
  • Phone: 312-256-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA MAYES
Title or Position: MANAGING MANGER
Credential:
Phone: 312-256-5459