Provider Demographics
NPI:1275764870
Name:LEGACY THERAPY CENTER, INC.
Entity Type:Organization
Organization Name:LEGACY THERAPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-855-0848
Mailing Address - Street 1:P.O. BOX 61140
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1140
Mailing Address - Country:US
Mailing Address - Phone:361-855-1352
Mailing Address - Fax:361-855-1254
Practice Address - Street 1:5633 S. STAPLES STREET
Practice Address - Street 2:SUITE 400 & 500
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78466-1140
Practice Address - Country:US
Practice Address - Phone:361-855-1352
Practice Address - Fax:361-855-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QR0401X
261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)