Healthcare Provider Details

I. General information

NPI: 1508581000
Provider Name (Legal Business Name): LEGACY LIVING HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3662 PATRICIA DR NW
CONCORD NC
28027-5625
US

IV. Provider business mailing address

11322 ERWIN RIDGE AVE
CHARLOTTE NC
28213-4863
US

V. Phone/Fax

Practice location:
  • Phone: 704-412-9906
  • Fax:
Mailing address:
  • Phone: 704-778-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: LORENZO MCNULTY
Title or Position: ADMINISTRATOR-IN-TRAINOR
Credential:
Phone: 704-778-9999