Healthcare Provider Details

I. General information

NPI: 1164264065
Provider Name (Legal Business Name): LEGACY SWEET HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 LANE RD
GREENE ME
04236-3111
US

IV. Provider business mailing address

170 LANE RD
GREENE ME
04236-3111
US

V. Phone/Fax

Practice location:
  • Phone: 774-287-8834
  • Fax:
Mailing address:
  • Phone: 774-287-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: THAMARA FARIA
Title or Position: MEMBER
Credential:
Phone: 774-287-8834