Provider Demographics
NPI:1710346879
Name:LEGENDARY LIFE SOLUTIONS, LLC
Entity Type:Organization
Organization Name:LEGENDARY LIFE SOLUTIONS, LLC
Other - Org Name:TRINITY LIFE SOLUTIONS OF NORTHWEST FLORIDA, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RHODES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-319-7358
Mailing Address - Street 1:921 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-4524
Mailing Address - Country:US
Mailing Address - Phone:850-319-7358
Mailing Address - Fax:
Practice Address - Street 1:2809 W 15TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1358
Practice Address - Country:US
Practice Address - Phone:850-778-2233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management