MEDICARE: LEGACY HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1255145611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	16003 E 107TH AVE
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-8723
Country	:	US
Telephone Number	:	317-702-2547
Fax Number	:

Provider Business Practice Location Address
First Line	:	16003 E 107TH AVE
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-8723
Country	:	US
Telephone Number	:	317-702-2547
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	OLAWALE SUNDAY FAKUADE
Credential	:
Telephone Number	:	317-702-2547

Provider Enumeration Date	:	02/05/2025
Last Update Date	:	02/05/2025

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