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General NPI Number Information
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NPI Number | 1225721707
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Entity Type | Organization
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Legal Business Name | LEGACY VILLAGE OUTPATIENT ID, LLC
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Dates
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Enumeration Date | 05/31/2023
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Last Update Date | 05/31/2023
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Provider Practice Location Address
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Address Line | 800 W MAIN ST STE 1460
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City | BOISE
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State | ID
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Zip | 83702-5983
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Country | US
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Telephone | 800-997-6977
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Fax | 661-489-0573
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Provider Business Mailing Address
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Address Line | 800 W MAIN ST STE 1460
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City | BOISE
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State | ID
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Zip | 83702-5983
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Country | US
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Telephone | 800-997-6977
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Fax | 661-489-0573
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. DENNIS SCOTT FARMER
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Credential |
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Telephone | 800-997-6977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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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 | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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