Healthcare Provider Details

I. General information

NPI: 1902075690
Provider Name (Legal Business Name): LEGACY HUMAN SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MUSTIAN ROAD WARREN COUNTY GROUP HOME
RIDGEWAY NC
27570
US

IV. Provider business mailing address

PO BOX 88
HENDERSON NC
27536-0088
US

V. Phone/Fax

Practice location:
  • Phone: 252-456-3177
  • Fax:
Mailing address:
  • Phone: 252-438-6700
  • Fax: 252-438-6720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL-093-031
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-093-031
License Number StateNC

VIII. Authorized Official

Name: JACINTA JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 252-438-6700