MEDICARE: LEGACY HEALING CENTER CALIFORNIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1003699752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HEALING CENTER CALIFORNIA LLC

Provider Business Mailing Address
First Line	:	4700 EXCHANGE CT STE 185
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33431-4000
Country	:	US
Telephone Number	:	561-308-0865
Fax Number	:

Provider Business Practice Location Address
First Line	:	2321 CASTILIAN DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-2614
Country	:	US
Telephone Number	:	561-308-0865
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	DAMARIS GONZALEZ
Credential	:
Telephone Number	:	561-308-0865

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	04/16/2026

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