Provider Demographics
NPI:1295406239
Name:LEGACY MEDICAL CLINICS
Entity Type:Organization
Organization Name:LEGACY MEDICAL CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-397-0449
Mailing Address - Street 1:15138 CHAPTER WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-1770
Mailing Address - Country:US
Mailing Address - Phone:985-397-0449
Mailing Address - Fax:
Practice Address - Street 1:8726 NW 26TH ST STE 16
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1628
Practice Address - Country:US
Practice Address - Phone:786-360-2901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty