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General NPI Number Information
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NPI Number | 1841108347
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Entity Type | Organization
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Legal Business Name | LEGACY HEALTHCARE GROUP
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Dates
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Enumeration Date | 08/28/2026
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Last Update Date | 08/28/2026
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Provider Practice Location Address
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Address Line | 5230 W MOONLIGHT MINE RD
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City | POCATELLO
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State | ID
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Zip | 83201-9013
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Country | US
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Telephone | 954-548-7312
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Fax | 954-548-7312
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Provider Business Mailing Address
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Address Line | 66 W FLAGLER ST STE 900
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City | MIAMI
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State | FL
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Zip | 33130-1807
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Country | US
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Telephone | 954-548-7312
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Fax | 954-548-7312
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Authorized Official
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Title or Position | OWNER
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Name | MR. EVERTON ANTHONY BOOTHE
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Credential | PMHNP-BC
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Telephone | 954-548-7312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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