=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316144397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY HOME CARE AGENCY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2007
-----------------------------------------------------
Last Update Date | 01/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615B LEWIS STREET SUITE 106
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-3523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-1067
-----------------------------------------------------
Fax | 919-693-1067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1814
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-1067
-----------------------------------------------------
Fax | 919-693-1067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. TRACY HASKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-693-1067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC3574
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------