Provider Demographics
NPI:1891749206
Name:LEGACY HEALTHCARE INC
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE INC
Other - Org Name:LEGACY PHYSICAL THERAPY & SPORTS TRAINING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-302-9400
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-1156
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2635
Practice Address - Country:US
Practice Address - Phone:941-906-7766
Practice Address - Fax:941-906-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB5339OtherMEDICARE RAILROAD GROUP
FL888322000Medicaid
FL2989794OtherAETNA GROUP PROV NUMBER
FLRY9OtherBCBS FACILITY ID
FLK3932Medicare PIN
FL888322000Medicaid