Healthcare Provider Details

I. General information

NPI: 1760915243
Provider Name (Legal Business Name): LEGACY HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 BOSQUE PLZ NW
ALBUQUERQUE NM
87120-4295
US

IV. Provider business mailing address

3610 BOSQUE PLZ NW
ALBUQUERQUE NM
87120-4295
US

V. Phone/Fax

Practice location:
  • Phone: 505-338-3702
  • Fax: 505-338-3709
Mailing address:
  • Phone: 505-338-3702
  • Fax: 505-338-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number3338
License Number StateNM

VIII. Authorized Official

Name: JIMMY MELTON
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 505-917-7998