Provider Demographics
NPI:1700465226
Name:LEGACY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:LEGACY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-263-3100
Mailing Address - Street 1:6741 SW 24TH ST STE 46
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1767
Mailing Address - Country:US
Mailing Address - Phone:786-427-7059
Mailing Address - Fax:
Practice Address - Street 1:6741 SW 24TH ST STE 46
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1767
Practice Address - Country:US
Practice Address - Phone:786-427-7059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-02
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101681100Medicaid