Provider Demographics
NPI:1497048078
Name:LEGACY BHC
Entity Type:Organization
Organization Name:LEGACY BHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TARGET CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PLACIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:TCM
Authorized Official - Phone:772-631-6892
Mailing Address - Street 1:4747 SE DUVAL DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-1504
Mailing Address - Country:US
Mailing Address - Phone:772-631-6892
Mailing Address - Fax:772-597-6399
Practice Address - Street 1:4747 SE DUVAL DRIVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997
Practice Address - Country:US
Practice Address - Phone:772-631-6892
Practice Address - Fax:772-597-6399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY BHC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization