Provider Demographics
NPI:1356030399
Name:LEGACY PROSTHETICS & ORTHOTICS
Entity type:Organization
Organization Name:LEGACY PROSTHETICS & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICEPRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEDEZMA
Authorized Official - Suffix:
Authorized Official - Credentials:CPOA
Authorized Official - Phone:760-216-3009
Mailing Address - Street 1:75150 SHERYL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-5118
Mailing Address - Country:US
Mailing Address - Phone:760-345-4779
Mailing Address - Fax:
Practice Address - Street 1:75150 SHERYL AVE STE A
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-5118
Practice Address - Country:US
Practice Address - Phone:760-345-4779
Practice Address - Fax:760-772-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier