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General NPI Number Information
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NPI Number | 1346693496
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Entity Type | Organization
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Legal Business Name | LEGENDARY SUPPORT COORDINATION, LLC
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Dates
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Enumeration Date | 07/13/2016
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Last Update Date | 07/13/2016
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Provider Practice Location Address
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Address Line | 4950 PARKSIDE AVE STE 102
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City | PHILADELPHIA
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State | PA
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Zip | 19131-4700
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Country | US
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Telephone | 215-596-5940
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Fax | 215-921-6188
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Provider Business Mailing Address
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Address Line | 4950 PARKSIDE AVE STE 102
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City | PHILADELPHIA
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State | PA
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Zip | 19131-4700
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Country | US
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Telephone | 215-596-5940
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Fax | 215-921-6188
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Authorized Official
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Title or Position | CEO
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Name | JAMES PETTAWAY
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Credential |
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Telephone | 215-596-5940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number |
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License Number State | PA
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