Healthcare Provider Details

I. General information

NPI: 1003773490
Provider Name (Legal Business Name): LEGENDARII SMITH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 PARKVIEW AVE APT 1
BRONX NY
10461-4660
US

IV. Provider business mailing address

1828 PARKVIEW AVE APT 1
BRONX NY
10461-4660
US

V. Phone/Fax

Practice location:
  • Phone: 347-692-6161
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DERRICK SMITH
Title or Position: PROVIDER
Credential:
Phone: 347-692-6161