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General NPI Number Information
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NPI Number | 1780737692
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Entity Type | Organization
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Legal Business Name | LEGACY HEALTHCARE CORPORATION
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 600 BACON ST
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City | MADISONVILLE
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State | TX
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Zip | 77864-2511
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Country | US
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Telephone | 936-348-9097
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Fax | 936-348-9212
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Provider Business Mailing Address
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Address Line | 600 BACON ST
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City | MADISONVILLE
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State | TX
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Zip | 77864-2511
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Country | US
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Telephone | 936-348-9097
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Fax | 936-348-9212
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Authorized Official
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Title or Position | PRESIDENT OF MANAGEMENT COMPANY
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Name | DOUGLAS K MITTLEIDER
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Credential |
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Telephone | 770-619-0866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 116849
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License Number State | TX
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