Healthcare Provider Details

I. General information

NPI: 1649688896
Provider Name (Legal Business Name): LEGACY BEHAVIORAL HEALTH,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 W SAX CANYON CT
ANTHEM AZ
85086-3657
US

IV. Provider business mailing address

2224 W SAX CANYON CT
ANTHEM AZ
85086-3657
US

V. Phone/Fax

Practice location:
  • Phone: 520-400-5709
  • Fax: 623-776-1776
Mailing address:
  • Phone: 520-400-5709
  • Fax: 623-776-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRIS ALAN BANKEN
Title or Position: CEO/FOUNDER
Credential: B.S.
Phone: 520-400-5709