Healthcare Provider Details

I. General information

NPI: 1831113463
Provider Name (Legal Business Name): LEGACY HEALTHCARE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BACON ST
MADISONVILLE TX
77864-2511
US

IV. Provider business mailing address

485 CENTRAL AVE NE
CLEVELAND TN
37311-5541
US

V. Phone/Fax

Practice location:
  • Phone: 936-348-9097
  • Fax: 936-348-9212
Mailing address:
  • Phone: 423-478-5953
  • Fax: 423-472-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number116849
License Number StateTX

VIII. Authorized Official

Name: TOM JOHNSON
Title or Position: OWNER
Credential:
Phone: 423-478-5953