=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114690906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY LEGACY HOME HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2021
-----------------------------------------------------
Last Update Date | 07/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12633 STONERIDGE DR
-----------------------------------------------------
City | BLACK JACK
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63033-4618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-651-7172
-----------------------------------------------------
Fax | 314-653-0258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12633 STONERIDGE DR
-----------------------------------------------------
City | BLACK JACK
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63033-4618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-651-7172
-----------------------------------------------------
Fax | 314-653-0258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER MEMBER
-----------------------------------------------------
Name | MRS. BRENDA GAIL MARSHALL
-----------------------------------------------------
Credential | AM
-----------------------------------------------------
Telephone | 314-651-7172
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------