MEDICARE: I AM LEGENDARY 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1962341693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I AM LEGENDARY LLC

Provider Business Mailing Address
First Line	:	3109 BOULEVARD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1931
Country	:	US
Telephone Number	:	904-898-8365
Fax Number	:

Provider Business Practice Location Address
First Line	:	3109 BOULEVARD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1931
Country	:	US
Telephone Number	:	904-898-8365
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CASSANDRA NICOLE SPENCER
Credential	:
Telephone Number	:	904-898-8365

Provider Enumeration Date	:	03/27/2026
Last Update Date	:	03/27/2026

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