Healthcare Provider Details

I. General information

NPI: 1912834243
Provider Name (Legal Business Name): LASTING LEGACY HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

463688 STATE ROAD 200 STE 1522
YULEE FL
32097-0304
US

IV. Provider business mailing address

81508 BOATSWAIN CT
FERNANDINA BEACH FL
32034-7118
US

V. Phone/Fax

Practice location:
  • Phone: 904-849-5192
  • Fax:
Mailing address:
  • Phone:
  • 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: HENRY BOLTON JR.
Title or Position: OWNER
Credential:
Phone: 706-564-1472