MEDICARE: LEGACY HEALTHCARE 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	225X00000X	Occupational Therapist
2	225100000X	Physical Therapist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DB5339	OTHER		MEDICARE RAILROAD GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2989794	OTHER	FL	AETNA GROUP PROV NUMBER
4	RY9	OTHER	FL	BCBS FACILITY ID

General Provider Information

NPI Number	:	1891749206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HEALTHCARE INC

Provider Business Mailing Address
First Line	:	PO BOX 1156
Second Line	:
City	:	ELLENTON
State	:	FL
Zip	:	34222-1156
Country	:	US
Telephone Number	:	941-729-0003
Fax Number	:	941-729-0004

Provider Business Practice Location Address
First Line	:	2650 BAHIA VISTA ST
Second Line	:	SUITE 101
City	:	SARASOTA
State	:	FL
Zip	:	34239-2635
Country	:	US
Telephone Number	:	941-906-7766
Fax Number	:	941-906-7767

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. CESAR CHACON
Credential	:
Telephone Number	:	941-302-9400

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/17/2015

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Directions to “LEGACY HEALTHCARE INC ” Practice Location

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