Provider Demographics
NPI:1295435303
Name:LEGACY PLACE RECOVERY, LLC
Entity type:Organization
Organization Name:LEGACY PLACE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:931-808-7504
Mailing Address - Street 1:5907 CLINTON HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2547
Mailing Address - Country:US
Mailing Address - Phone:931-808-7504
Mailing Address - Fax:
Practice Address - Street 1:711 E OLDHAM AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5566
Practice Address - Country:US
Practice Address - Phone:865-471-8326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty