Provider Demographics
NPI:1801244330
Name:LEGEND RECOVERY
Entity type:Organization
Organization Name:LEGEND RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YEDIDSION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-474-7211
Mailing Address - Street 1:10700 SANTA MONICA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6588
Mailing Address - Country:US
Mailing Address - Phone:310-474-7211
Mailing Address - Fax:
Practice Address - Street 1:10700 SANTA MONICA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6588
Practice Address - Country:US
Practice Address - Phone:310-474-7211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OVERNIGHT DIAGNOSTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-25
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility