Provider Demographics
NPI:1578089983
Name:LEGENDARY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LEGENDARY PHYSICAL THERAPY LLC
Other - Org Name:LEGENDARY PHYSICAL THERAPY AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:III
Authorized Official - Credentials:PT, DPT, COMT
Authorized Official - Phone:850-380-4377
Mailing Address - Street 1:PO BOX 6568
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-0568
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:410 N PALAFOX ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3919
Practice Address - Country:US
Practice Address - Phone:850-332-7681
Practice Address - Fax:850-512-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022219700Medicaid
FL1568589588OtherLOUIE WATKINS III NPI NUMBER