Healthcare Provider Details

I. General information

NPI: 1689840266
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 EDNA LN
LONGVIEW TX
75602-4915
US

IV. Provider business mailing address

1517 EDNA LN
LONGVIEW TX
75602-4915
US

V. Phone/Fax

Practice location:
  • Phone: 903-557-0746
  • Fax:
Mailing address:
  • Phone: 903-557-0746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number209900
License Number StateTX

VIII. Authorized Official

Name: MS. KATRINA DENEAN JOHNSON
Title or Position: C.O.T.A.
Credential:
Phone: 903-557-0746