Healthcare Provider Details

I. General information

NPI: 1528627015
Provider Name (Legal Business Name): LEGACY OF FAITH HOMECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4903 BLUE SKY WAY
MARIANNA FL
32446-1864
US

IV. Provider business mailing address

4903 BLUE SKY WAY
MARIANNA FL
32446-1864
US

V. Phone/Fax

Practice location:
  • Phone: 850-557-7128
  • Fax:
Mailing address:
  • Phone: 850-557-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELICA WEBB
Title or Position: OWNER
Credential:
Phone: 850-557-7128