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General NPI Number Information
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NPI Number | 1255064291
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Entity Type | Organization
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Legal Business Name | LEGACY CORE HEALTH LLC
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Dates
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Enumeration Date | 07/07/2022
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Last Update Date | 07/20/2022
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Provider Practice Location Address
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Address Line | 9415 S WESTERN AVE STE 235
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City | CHICAGO
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State | IL
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Zip | 60643-6700
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Country | US
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Telephone | 708-321-1233
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Fax |
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Provider Business Mailing Address
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Address Line | 9415 S WESTERN AVE STE 235
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City | CHICAGO
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State | IL
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Zip | 60643-6700
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Country | US
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Telephone | 708-321-1233
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JOSEPHINE EBOMOYI
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Credential |
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Telephone | 970-397-8140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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