Provider Demographics
NPI:1477991073
Name:M & D LEGACY
Entity type:Organization
Organization Name:M & D LEGACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:800-971-7970
Mailing Address - Street 1:1404 RAINBOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-8106
Mailing Address - Country:US
Mailing Address - Phone:800-971-7970
Mailing Address - Fax:800-971-7978
Practice Address - Street 1:1920 N ZARAGOZA RD
Practice Address - Street 2:SUITE 108
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-4655
Practice Address - Country:US
Practice Address - Phone:800-971-7970
Practice Address - Fax:800-971-7978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109054225XP0200X
TX104537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty