Provider Demographics
NPI:1659193357
Name:LEGACY BEHAVIORAL HEALTH CENTER
Entity type:Organization
Organization Name:LEGACY BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:RAFAEL
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-253-1770
Mailing Address - Street 1:518 SW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8734
Mailing Address - Country:US
Mailing Address - Phone:772-873-8811
Mailing Address - Fax:772-873-8800
Practice Address - Street 1:518 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8734
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:772-873-8800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY BEHAVIORAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty