MEDICARE: LEGENDARY LIFE SOLUTIONS, 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	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710346879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGENDARY LIFE SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	921 N CENTER AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-4524
Country	:	US
Telephone Number	:	850-319-7358
Fax Number	:

Provider Business Practice Location Address
First Line	:	2809 W 15TH ST
Second Line	:	SUITE 102
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-1358
Country	:	US
Telephone Number	:	850-778-2233
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE DIRECTOR
Name	:	ALESIA RHODES
Credential	:
Telephone Number	:	850-319-7358

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	12/20/2016

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Directions to “LEGENDARY LIFE SOLUTIONS, LLC ” Practice Location

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