MEDICARE: LEGACY CORE HEALTH 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1255064291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CORE HEALTH LLC

Provider Business Mailing Address
First Line	:	9415 S WESTERN AVE STE 235
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-6700
Country	:	US
Telephone Number	:	708-321-1233
Fax Number	:

Provider Business Practice Location Address
First Line	:	9415 S WESTERN AVE STE 235
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-6700
Country	:	US
Telephone Number	:	708-321-1233
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOSEPHINE EBOMOYI
Credential	:
Telephone Number	:	970-397-8140

Provider Enumeration Date	:	07/07/2022
Last Update Date	:	07/20/2022

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