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General NPI Number Information
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NPI Number | 1295435303
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Entity Type | Organization
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Legal Business Name | LEGACY PLACE RECOVERY, LLC
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Dates
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Enumeration Date | 03/07/2023
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 711 E OLDHAM AVE
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City | KNOXVILLE
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State | TN
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Zip | 37917-5566
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Country | US
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Telephone | 865-471-8326
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Fax |
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Provider Business Mailing Address
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Address Line | 5907 CLINTON HWY
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City | KNOXVILLE
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State | TN
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Zip | 37912-2547
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Country | US
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Telephone | 931-808-7504
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | JOSHUA DAVENPORT
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Credential | PA-C
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Telephone | 931-808-7504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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