Healthcare Provider Details

I. General information

NPI: 1275764870
Provider Name (Legal Business Name): LEGACY THERAPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5633 S. STAPLES STREET SUITE 400 & 500
CORPUS CHRISTI TX
78466-1140
US

IV. Provider business mailing address

P.O. BOX 61140
CORPUS CHRISTI TX
78466-1140
US

V. Phone/Fax

Practice location:
  • Phone: 361-855-1352
  • Fax: 361-855-1254
Mailing address:
  • Phone: 361-855-1352
  • Fax: 361-855-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. AMBROSE HERNANDEZ
Title or Position: CEO/OWNER
Credential:
Phone: 361-855-0848