Healthcare Provider Details

I. General information

NPI: 1104823038
Provider Name (Legal Business Name): LEGACY HOSPICE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S PROGRESS AVE SUITE 2A
MERIDIAN ID
83642-2957
US

IV. Provider business mailing address

680 S PROGRESS AVE SUITE 2A
MERIDIAN ID
83642-2958
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-8686
  • Fax: 208-895-8975
Mailing address:
  • Phone: 208-895-8686
  • Fax: 208-895-8975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateID

VIII. Authorized Official

Name: CHRISTIE LYNN ROACH
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 208-895-8686