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General NPI Number Information
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NPI Number | 1285757187
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Entity Type | Organization
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Legal Business Name | LEGACY HOUSE
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Dates
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Enumeration Date | 04/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6893 HAPPY VALLEY RD
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City | ANDERSON
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State | CA
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Zip | 96007-9526
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Country | US
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Telephone | 530-365-9119
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Fax |
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Provider Business Mailing Address
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Address Line | 190 WHITMORE LN
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City | UKIAH
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State | CA
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Zip | 95482-6932
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Country | US
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Telephone | 707-467-0911
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVID I NERVO
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Credential |
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Telephone | 707-467-0911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State | CA
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