Provider Demographics
NPI:1396122909
Name:LEGENDARY SUPPORT COORDINATION LLC
Entity type:Organization
Organization Name:LEGENDARY SUPPORT COORDINATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:MARLENA
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-231-9827
Mailing Address - Street 1:5860 MARKET ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3113
Mailing Address - Country:US
Mailing Address - Phone:215-596-5940
Mailing Address - Fax:
Practice Address - Street 1:5860 MARKET ST APT 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3113
Practice Address - Country:US
Practice Address - Phone:215-596-5940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management