Basic Information
| Provider Information | |||||||||
| NPI: | 1902081573 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY MEDICAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AEROCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 BARTLETT BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328116428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075152070 | ||||||||
| FaxNumber: | 8882476584 | ||||||||
| Practice Location | |||||||||
| Address1: | 4469 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373359199 | ||||||||
| FaxNumber: | 9372981250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEROCARE HOLDINGS, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 2881172 | 05 | OH | MEDICAID |