{
"Npi": {
"NPI": "1518810662",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LEGACY MEDICAL GROUP CORP",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "17641 SW 84TH CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PALMETTO BAY",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33157-6014",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "889-808-7501",
"MailingAddressFaxNumber": "889-876-3737",
"FirstLinePracticeLocationAddress": "7351 W OAKLAND PARK BLVD STE 103",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "TAMARAC",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33319-7107",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "889-808-7501",
"PracticeLocationAddressFaxNumber": "889-876-3737",
"EnumerationDate": "02/18/2026",
"LastUpdateDate": "02/18/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GALVEZ",
"AuthorizedOfficialFirstName": "JORGE",
"AuthorizedOfficialMiddleName": "FELIX",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RN",
"AuthorizedOfficialTelephoneNumber": "505-967-1651",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208D00000X",
"TaxonomyName": "General Practice Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}