MEDICARE: LEGACY MARKETING WORLDWIDE INC.

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	261QP2300X	Primary Care Clinic/Center
2	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1336505197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY MARKETING WORLDWIDE INC.

Provider Business Mailing Address
First Line	:	5015 EAGLE ROCK BLVD STE 205
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-2087
Country	:	US
Telephone Number	:	747-300-7541
Fax Number	:	818-471-4287

Provider Business Practice Location Address
First Line	:	5015 EAGLE ROCK BLVD STE 205
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-2087
Country	:	US
Telephone Number	:	747-300-7541
Fax Number	:	818-471-4287

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MARLON C SALAMAT
Credential	:	ADMINISTRATOR
Telephone Number	:	747-300-7541

Provider Enumeration Date	:	01/11/2016
Last Update Date	:	10/09/2023

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