Healthcare Provider Details

I. General information

NPI: 1689597486
Provider Name (Legal Business Name): LEGACY DREAM HOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MIMOSA DR
PALATKA FL
32177-6425
US

IV. Provider business mailing address

210 MIMOSA DR
PALATKA FL
32177-6425
US

V. Phone/Fax

Practice location:
  • Phone: 386-546-6049
  • Fax:
Mailing address:
  • Phone: 386-546-6049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name: DARRENTON K HARRIS SR.
Title or Position: PRESIDENT
Credential: BBA,MBA
Phone: 386-546-6049