Healthcare Provider Details

I. General information

NPI: 1265910038
Provider Name (Legal Business Name): LEGENDARY IN-HOME SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 CHARLES LN
PONTIAC MI
48341-2930
US

IV. Provider business mailing address

269 CHARLES LN
PONTIAC MI
48341-2930
US

V. Phone/Fax

Practice location:
  • Phone: 313-757-1843
  • Fax:
Mailing address:
  • Phone: 313-757-1843
  • 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 Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateMI

VIII. Authorized Official

Name: TENESIA GERMAN
Title or Position: PRESIDENT
Credential:
Phone: 678-618-7932