Healthcare Provider Details

I. General information

NPI: 1376123356
Provider Name (Legal Business Name): LEGACY CARE SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11073 LEXINGTON DR
DUNCANVILLE AL
35456-2213
US

IV. Provider business mailing address

11073 LEXINGTON DR
DUNCANVILLE AL
35456-2213
US

V. Phone/Fax

Practice location:
  • Phone: 205-792-3690
  • Fax:
Mailing address:
  • Phone: 205-792-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. VERANDA K. MELTON
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: DNP
Phone: 205-792-3690