{
"Npi": {
"NPI": "1578089983",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LEGENDARY PHYSICAL THERAPY LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 6568",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PENSACOLA",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32503-0568",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "850-478-1312",
"MailingAddressFaxNumber": "850-474-9060",
"FirstLinePracticeLocationAddress": "410 N PALAFOX ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PENSACOLA",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32501-3919",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "850-332-7681",
"PracticeLocationAddressFaxNumber": "850-512-1188",
"EnumerationDate": "08/17/2017",
"LastUpdateDate": "01/24/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WATKINS",
"AuthorizedOfficialFirstName": "LOUIE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHYSICAL THERAPIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "III",
"AuthorizedOfficialCredential": "PT, DPT, COMT",
"AuthorizedOfficialTelephoneNumber": "850-380-4377",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QP2000X",
"TaxonomyName": "Physical Therapy Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}