Healthcare Provider Details

I. General information

NPI: 1831908169
Provider Name (Legal Business Name): LEGENDARY HOMECARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2593 4TH ST W APT 308
DICKINSON ND
58601-2447
US

IV. Provider business mailing address

2593 4TH ST W APT 308
DICKINSON ND
58601-2447
US

V. Phone/Fax

Practice location:
  • Phone: 215-485-2276
  • Fax:
Mailing address:
  • Phone: 215-485-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ERNEST GALISON GIBSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 215-485-2276