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LEGACY TREATMENT CENTER LLC
NPI 1336940717
Family Medicine - Addiction Medicine in Fort Wayne, IN

Active since March 21, 2025CLIA 15D2329520 · Waiver
3030 LAKE AVE STE 24, FORT WAYNE, IN 46805(260) 705-4587 Get Directions Write a Review

NPPES record last updated: December 12, 2025. Verified against the NPPES registry weekly; last sync: August 02, 2026.

Record update history: Dec 12, 2025, Apr 6, 2025, Mar 21, 2025 (3 updates tracked since 2025).

About Legacy Treatment Center Llc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

LEGACY TREATMENT CENTER LLC (NPI 1336940717) is a healthcare organization registered as an addiction medicine in Fort Wayne, Indiana and active in the NPI registry since March 2025. The organization holds a CLIA Waiver certificate valid through August 28, 2027 and lists Abdul Barrie, Ceo, as its authorized official.

NPPES Registry Identity

NPI1336940717
Entity TypeOrganization
Primary Taxonomy207QA0401X
Legal Business NameLEGACY TREATMENT CENTER LLC
Location Address3030 LAKE AVE STE 24Fort Wayne, IN 46805-5428
Mailing Address3030 Lake Ave Ste 24Fort Wayne, IN 46805-5428 · (260) 705-4587
Phone(260) 705-4587
Organization SubpartNo
Authorized OfficialAbdul BarrieCeo · (260) 201-3119
Enumeration DateMarch 21, 2025
Last NPPES UpdateDecember 12, 20253 updates tracked since enumeration
NPPES CertifiedDecember 12, 2025
✔ NPI 1336940717 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyFamily Medicine · Addiction MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207QA0401X
Definition
A family medicine physician who specializes in the diagnosis and treatment of addictions.
3030 LAKE AVE STE 24, Fort Wayne, IN 46805
Open in Google Maps ↗

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 15D2329520

Legacy Treatment Center · Fort Wayne, IN
Active · expires Aug 28, 2027
CLIA Number15D2329520
Laboratory TypePractitioner Other
Certificate Effective DateAugust 29, 2025
Certificate Expiration DateAugust 28, 2027
Laboratory DirectorAbdul Barrie
Laboratory Phone(260) 705-4587
Laboratory LocationLegacy Treatment Center3030 Lake Ave Ste 24, Fort Wayne, IN 46805
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 3

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MRS. KATHLEEN VANDERREYDEN NP
Nurse Practitioner
3030 LAKE AVE STE 24
FORT WAYNE, IN 46805
Allen County (260) 201-3119
JENNIFER LEA SCHEIDERER PT
Physical Therapist
3030 LAKE AVE STE 24
FORT WAYNE, IN 46805
Allen County (260) 424-8830
MRS. LAURY FARRELL FNP
Nurse Practitioner
3030 LAKE AVE STE 24
FORT WAYNE, IN 46805
Allen County (260) 705-4587

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Legacy Treatment Center LLC's NPI number?

The NPI number for Legacy Treatment Center LLC is 1336940717. It was assigned to this organization in the NPPES registry on March 21, 2025.

Where is Legacy Treatment Center LLC located?

Legacy Treatment Center LLC is located at 3030 Lake Ave Ste 24, Fort Wayne, IN 46805. The listed phone number is (260) 705-4587.

What is Legacy Treatment Center LLC's specialty?

The primary specialty registered for this NPI is Family Medicine, specializing in Addiction Medicine, with taxonomy code 207QA0401X.

Does Legacy Treatment Center LLC hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 15D2329520) is associated with this NPI, valid through August 28, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Legacy Treatment Center LLC was last updated on December 12, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 7 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.