Healthcare Provider Details

I. General information

NPI: 1730334640
Provider Name (Legal Business Name): LEGACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 FM 105
ORANGE TX
77630-1272
US

IV. Provider business mailing address

4201 FM 105
ORANGE TX
77630-1272
US

V. Phone/Fax

Practice location:
  • Phone: 409-670-1457
  • Fax:
Mailing address:
  • Phone: 409-670-1457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2019808
License Number StateTX

VIII. Authorized Official

Name: LARRY DEAN SCHMUCK
Title or Position: PTA/STAFF
Credential:
Phone: 409-962-4195