Provider Demographics
NPI:1679249981
Name:LEGACY850 LLC
Entity Type:Organization
Organization Name:LEGACY850 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-868-1002
Mailing Address - Street 1:PO BOX 1701
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32353-1701
Mailing Address - Country:US
Mailing Address - Phone:850-868-1002
Mailing Address - Fax:
Practice Address - Street 1:111 HENRY DRIVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:FL
Practice Address - Zip Code:32332
Practice Address - Country:US
Practice Address - Phone:850-868-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities