Provider Demographics
NPI:1669333696
Name:LEGACY MED PRO
Entity type:Organization
Organization Name:LEGACY MED PRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-247-9084
Mailing Address - Street 1:407 LAKE HOWELL RD STE 1011
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5914
Mailing Address - Country:US
Mailing Address - Phone:224-247-9084
Mailing Address - Fax:
Practice Address - Street 1:407 LAKE HOWELL RD STE 1011
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5914
Practice Address - Country:US
Practice Address - Phone:224-247-9084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-19
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies