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General NPI Number Information
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NPI Number | 1104615467
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Entity Type | Organization
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Legal Business Name | LEGACY SMALL FAMILY HOME
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Dates
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Enumeration Date | 05/03/2025
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 3950 REYNOLDS RD
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City | RIVERSIDE
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State | CA
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Zip | 92503-3517
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Country | US
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Telephone | 951-358-4466
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Fax |
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Provider Business Mailing Address
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Address Line | 32675 MISSION TRL APT 41
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City | LAKE ELSINORE
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State | CA
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Zip | 92530-2330
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Country | US
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Telephone | 562-253-9674
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Fax |
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Authorized Official
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Title or Position | REGISTERED NURSE
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Name | MONIQUE LEONARD
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Credential | RN
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Telephone | 562-253-9674
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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