Healthcare Provider Details

I. General information

NPI: 1104615467
Provider Name (Legal Business Name): LEGACY SMALL FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2025
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 REYNOLDS RD
RIVERSIDE CA
92503-3517
US

IV. Provider business mailing address

2320 RIVENDELL RD
PERRIS CA
92570-2708
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4466
  • Fax:
Mailing address:
  • Phone: 562-253-9674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE LEONARD
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 562-253-9674