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General NPI Number Information
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NPI Number | 1710346879
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Entity Type | Organization
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Legal Business Name | LEGENDARY LIFE SOLUTIONS, LLC
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Dates
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Enumeration Date | 02/17/2016
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Last Update Date | 12/20/2016
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Provider Practice Location Address
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Address Line | 2809 W 15TH ST SUITE 102
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City | PANAMA CITY
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State | FL
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Zip | 32401-1358
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Country | US
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Telephone | 850-778-2233
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Fax |
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Provider Business Mailing Address
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Address Line | 921 N CENTER AVE
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City | PANAMA CITY
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State | FL
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Zip | 32401-4524
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Country | US
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Telephone | 850-319-7358
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE DIRECTOR
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Name | ALESIA RHODES
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Credential |
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Telephone | 850-319-7358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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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