Provider Demographics
NPI:1053815654
Name:LEGACY OUTPATIENT THERAPY SERVICES
Entity type:Organization
Organization Name:LEGACY OUTPATIENT THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JILL RAIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN, MSN, FNP-C
Authorized Official - Phone:562-467-0777
Mailing Address - Street 1:11618 SOUTH ST # 201
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-6618
Mailing Address - Country:US
Mailing Address - Phone:562-467-0777
Mailing Address - Fax:
Practice Address - Street 1:11618 SOUTH ST UNIT 201
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701
Practice Address - Country:US
Practice Address - Phone:562-467-0777
Practice Address - Fax:562-683-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty