Healthcare Provider Details

I. General information

NPI: 1992634943
Provider Name (Legal Business Name): LEGACY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5531 EDEN PRAIRIE RD
MINNETONKA MN
55345-5842
US

IV. Provider business mailing address

5531 EDEN PRAIRIE RD
MINNETONKA MN
55345-5842
US

V. Phone/Fax

Practice location:
  • Phone: 612-964-8376
  • Fax: 763-201-5991
Mailing address:
  • Phone: 612-964-8376
  • Fax: 763-201-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE FRYER
Title or Position: DIRECTOR OF OPERATIONS
Credential: LALD
Phone: 763-300-7875