Healthcare Provider Details

I. General information

NPI: 1073427571
Provider Name (Legal Business Name): LEGACY HAVEN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17455 SAMUEL ST
BENNINGTON NE
68007-1967
US

IV. Provider business mailing address

PO BOX 12332
OMAHA NE
68112-0332
US

V. Phone/Fax

Practice location:
  • Phone: 402-505-2664
  • Fax:
Mailing address:
  • Phone: 402-505-2664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MONETTA LATRICE PRINCE
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 816-756-7508