1124228317 NPI number — LEGACY HOME HEALTH AGENCY, INC

Table of content: (NPI 1124228317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124228317 NPI number — LEGACY HOME HEALTH AGENCY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY HOME HEALTH AGENCY, INC
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:
1124228317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6655 FIRST PARK TEN BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78213-4304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-736-1855
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5277 OLD BROWNSVILLE RD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78405-3930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-855-0848
Provider Business Practice Location Address Fax Number:
361-853-4855
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
AMBROSE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
361-855-0848

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  008442 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8616 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001003937 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001013242 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001003938 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001015098 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D0945503 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com