MEDICARE: LEGACY III, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1508371154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY III, INC.

Provider Business Mailing Address
First Line	:	733 W MARKET ST STE B5A
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44303-1009
Country	:	US
Telephone Number	:	330-375-0071
Fax Number	:	330-375-0072

Provider Business Practice Location Address
First Line	:	733 W MARKET ST STE B5A
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44303-1009
Country	:	US
Telephone Number	:	330-375-0071
Fax Number	:	330-375-0072

Authorized Official
Title or Position	:	BOOKKEEPER
Name	:	MR. GARY A. MORGAN
Credential	:
Telephone Number	:	330-375-0071

Provider Enumeration Date	:	12/05/2017
Last Update Date	:	12/05/2017

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