Provider Demographics
NPI:1831662352
Name:LEGACY HEALING DETOX, LLC
Entity Type:Organization
Organization Name:LEGACY HEALING DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MASSIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EFFRON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:954-512-7792
Mailing Address - Street 1:803 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-5604
Mailing Address - Country:US
Mailing Address - Phone:561-308-0865
Mailing Address - Fax:
Practice Address - Street 1:803 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-5604
Practice Address - Country:US
Practice Address - Phone:561-308-0865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility