Provider Demographics
NPI:1063860666
Name:LEGACY FREEDOM TREATMENT CENTER
Entity Type:Organization
Organization Name:LEGACY FREEDOM TREATMENT CENTER
Other - Org Name:LEGACY TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-560-5238
Mailing Address - Street 1:445 DOLLEY MADISON RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-5165
Mailing Address - Country:US
Mailing Address - Phone:954-560-5238
Mailing Address - Fax:888-510-9071
Practice Address - Street 1:4944 PARKWAY PLAZA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1972
Practice Address - Country:US
Practice Address - Phone:954-560-5238
Practice Address - Fax:888-510-9071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL0601265324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL0601265OtherSTATE LICENSE