Healthcare Provider Details

I. General information

NPI: 1346189362
Provider Name (Legal Business Name): LEGACY HARBOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 SPARROW LN
SAN JACINTO CA
92582-6970
US

IV. Provider business mailing address

496 SPARROW LN
SAN JACINTO CA
92582-6970
US

V. Phone/Fax

Practice location:
  • Phone: 901-297-0393
  • Fax:
Mailing address:
  • Phone: 901-297-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JULIUS WATTS
Title or Position: OWNER
Credential:
Phone: 901-297-0393