Provider Demographics
NPI:1649402108
Name:LEGACY HEALTHCARE INC.
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-590-3948
Mailing Address - Street 1:1608 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5720
Mailing Address - Country:US
Mailing Address - Phone:970-590-3948
Mailing Address - Fax:
Practice Address - Street 1:1608 29TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-5720
Practice Address - Country:US
Practice Address - Phone:970-590-3948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2251500000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy