Provider Demographics
NPI:1154375715
Name:LEGACY HEALTHCARE INC
Entity type:Organization
Organization Name:LEGACY HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-302-9400
Mailing Address - Street 1:1144 TALLEVAST RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-3267
Mailing Address - Country:US
Mailing Address - Phone:941-355-9601
Mailing Address - Fax:941-355-9608
Practice Address - Street 1:7254 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-5554
Practice Address - Country:US
Practice Address - Phone:941-924-7819
Practice Address - Fax:941-924-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2989794OtherAETNA GROUP PROV NUM
FLRY8OtherBCBS FACILITY ID
FLRY8OtherBCBS FACILITY ID
FL686750Medicare Oscar/Certification