=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578066890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEXUS LEGACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2018
-----------------------------------------------------
Last Update Date | 06/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 S SUNSET AVE STE 202
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-480-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1314 MEADOW LN
-----------------------------------------------------
City | DUARTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91010-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-679-3645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. JARED EVANGELISTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-429-9220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------