Provider Demographics
NPI:1912518952
Name:LEGACY MEDICAL CLINIC WITH MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:LEGACY MEDICAL CLINIC WITH MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF THE ENTITY
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUKS
Authorized Official - Middle Name:E
Authorized Official - Last Name:NWAULU
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC
Authorized Official - Phone:301-880-4900
Mailing Address - Street 1:9509 MANOR OAKS VW
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3192
Mailing Address - Country:US
Mailing Address - Phone:301-880-4900
Mailing Address - Fax:301-477-4673
Practice Address - Street 1:4700 STAMP RD STE K
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-6717
Practice Address - Country:US
Practice Address - Phone:301-880-4900
Practice Address - Fax:301-477-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty