Healthcare Provider Details

I. General information

NPI: 1437062791
Provider Name (Legal Business Name): LEGACY RESIDENTIAL SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 MAIN ST
PARSONS KS
67357-2725
US

IV. Provider business mailing address

2405 MAIN ST
PARSONS KS
67357-2725
US

V. Phone/Fax

Practice location:
  • Phone: 620-833-4967
  • Fax:
Mailing address:
  • Phone: 620-833-4967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: SCOTTIE NICOLE COOK
Title or Position: OWNER
Credential:
Phone: 620-833-4967