Healthcare Provider Details

I. General information

NPI: 1316454952
Provider Name (Legal Business Name): LEGACY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W PORT PLZ FL 6
SAINT LOUIS MO
63146-3011
US

IV. Provider business mailing address

111 W PORT PLZ FL 6
SAINT LOUIS MO
63146-3011
US

V. Phone/Fax

Practice location:
  • Phone: 314-542-3121
  • Fax: 314-480-8301
Mailing address:
  • Phone: 314-542-3121
  • Fax: 314-480-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LATOYA THOMPSON
Title or Position: DIRECTOR
Credential:
Phone: 314-542-3121