Provider Demographics
NPI:1235183021
Name:LEGACY HEALTHCARE INC
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE INC
Other - Org Name:LEGACY PHYSICAL THERAPY & SPORTS TRAINING
Other - Org Type:Doing Business As
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:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-1156
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:4134 GULF OF MEXICO DR
Practice Address - Street 2:SUITE 209
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228-2612
Practice Address - Country:US
Practice Address - Phone:941-383-0414
Practice Address - Fax:941-383-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-08-17
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
FL2989794OtherAETNA GROUP PROVIDER NUM
FL888322000Medicaid
FLY919HOtherBCBS FACILITY NUMBER
DB5339OtherRAIL ROAD GROUP
FL888322000Medicaid