Healthcare Provider Details

I. General information

NPI: 1326915638
Provider Name (Legal Business Name): LEGACY LIVING CARE OF MICHIGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BURGUNDY CT
STONE MOUNTAIN GA
30087-4713
US

IV. Provider business mailing address

475 BURGUNDY CT
STONE MOUNTAIN GA
30087-4713
US

V. Phone/Fax

Practice location:
  • Phone: 404-989-8279
  • Fax:
Mailing address:
  • Phone: 404-989-8279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANKIVIA DAUGHERTY
Title or Position: CEO
Credential:
Phone: 404-989-8279