Healthcare Provider Details

I. General information

NPI: 1407735095
Provider Name (Legal Business Name): LEGACY1864, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 E MEAD ST
SPOKANE WA
99218-1772
US

IV. Provider business mailing address

PO BOX 1438
MEAD WA
99021-1438
US

V. Phone/Fax

Practice location:
  • Phone: 509-467-1135
  • Fax: 509-468-7906
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: RYAN KNUDSON
Title or Position: CEO/PRESIDENT
Credential:
Phone: 509-954-6919