MEDICARE: LEGACY TREATMENT CENTER 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	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1336940717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	3030 LAKE AVE STE 24
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5428
Country	:	US
Telephone Number	:	260-705-4587
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 LAKE AVE STE 24
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5428
Country	:	US
Telephone Number	:	260-705-4587
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ABDUL BARRIE
Credential	:
Telephone Number	:	260-201-3119

Provider Enumeration Date	:	03/21/2025
Last Update Date	:	12/12/2025

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