Healthcare Provider Details

I. General information

NPI: 1639927585
Provider Name (Legal Business Name): LEGACY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2914 W SOLANO DR S
PHOENIX AZ
85017-2543
US

IV. Provider business mailing address

4327 W MALDONADO RD
LAVEEN AZ
85339-6227
US

V. Phone/Fax

Practice location:
  • Phone: 480-349-0813
  • Fax:
Mailing address:
  • Phone: 480-349-0813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: SIMON AMEDAI
Title or Position: OWNER
Credential:
Phone: 480-349-0813