Provider Demographics
NPI:1972556017
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 1:7216 US HIGHWAY 301 N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-3462
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:834 PINEBROOK RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7123
Practice Address - Country:US
Practice Address - Phone:941-484-8107
Practice Address - Fax:941-484-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-07-31
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
FLY901XOtherBCBS FACILITY NUMBER
FL2989794OtherAETNA GROUP PROV NUMBER
FL888322000Medicaid
FL2989794OtherAETNA GROUP PROV NUMBER
FLY901XOtherBCBS FACILITY NUMBER