Provider Demographics
NPI:1578904603
Name:LEGACY TREATMENT CENTER
Entity Type:Organization
Organization Name:LEGACY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:IACULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-715-9288
Mailing Address - Street 1:4421 STUART ANDREW BLVD
Mailing Address - Street 2:SUITE 608
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4421 STUART ANDREW BLVD
Practice Address - Street 2:SUITE 608
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1589
Practice Address - Country:US
Practice Address - Phone:704-405-0908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D2055755291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory