MEDICARE: LEGACY II INCORPORATED

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	347B00000X	Bus	3699	MD
2	347C00000X	Private Vehicle	3699	MD

General Provider Information

NPI Number	:	1992955660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY II INCORPORATED

Provider Business Mailing Address
First Line	:	3195 OLD WASHINGTON RD
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3201
Country	:	US
Telephone Number	:	301-645-5466
Fax Number	:

Provider Business Practice Location Address
First Line	:	3195 OLD WASHINGTON RD
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3201
Country	:	US
Telephone Number	:	301-645-5466
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOHNNIE EARL LOVEDAY JR.
Credential	:
Telephone Number	:	301-645-5466

Provider Enumeration Date	:	09/30/2008
Last Update Date	:	09/30/2008

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Directions to “LEGACY II INCORPORATED ” Practice Location

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