Provider Demographics
NPI:1003699752
Name:LEGACY HEALING CENTER CALIFORNIA LLC
Entity Type:Organization
Organization Name:LEGACY HEALING CENTER CALIFORNIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-308-0865
Mailing Address - Street 1:1425 W CYPRESS CREEK RD STE 200201
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1916
Mailing Address - Country:US
Mailing Address - Phone:561-308-0865
Mailing Address - Fax:
Practice Address - Street 1:2462 SOLAR DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-1741
Practice Address - Country:US
Practice Address - Phone:561-308-0865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility