1114690906 NPI number — FAMILY LEGACY HOME HEALTH CARE

Table of content: (NPI 1114690906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114690906 NPI number — FAMILY LEGACY HOME HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY LEGACY HOME HEALTH CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114690906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12633 STONERIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACK JACK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63033-4618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-651-7172
Provider Business Mailing Address Fax Number:
314-653-0258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12633 STONERIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK JACK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63033-4618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-651-7172
Provider Business Practice Location Address Fax Number:
314-653-0258
Provider Enumeration Date:
07/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
GAIL
Authorized Official Title or Position:
OWNER MEMBER
Authorized Official Telephone Number:
314-651-7172

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com