Provider Demographics
NPI:1619489762
Name:MARS LEGACY LLC
Entity Type:Organization
Organization Name:MARS LEGACY LLC
Other - Org Name:LEGACY CHIRORPACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-203-1222
Mailing Address - Street 1:230 E MARKS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3819
Mailing Address - Country:US
Mailing Address - Phone:407-203-1222
Mailing Address - Fax:407-203-1223
Practice Address - Street 1:230 E MARKS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3819
Practice Address - Country:US
Practice Address - Phone:407-203-1222
Practice Address - Fax:407-203-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1881975803Medicaid