Provider Demographics
NPI:1053621607
Name:LEGACY
Entity type:Organization
Organization Name:LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:PARVIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AYREMPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:847-670-7214
Mailing Address - Street 1:120 SOUTH HI LUSI AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056
Mailing Address - Country:US
Mailing Address - Phone:847-670-7214
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH HI LUSI AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056
Practice Address - Country:US
Practice Address - Phone:847-670-7214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002590261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy