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General NPI Number Information
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NPI Number | 1659717692
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Entity Type | Organization
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Legal Business Name | LEGACY CARE HOME
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Dates
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Enumeration Date | 05/17/2013
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Last Update Date | 05/17/2013
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Provider Practice Location Address
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Address Line | 14900 CROWN DR
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City | MINNETONKA
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State | MN
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Zip | 55345-3603
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Country | US
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Telephone | 612-597-3153
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Fax |
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Provider Business Mailing Address
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Address Line | 14900 CROWN DR
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City | MINNETONKA
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State | MN
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Zip | 55345-3603
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/EXECUTIVE DIRECT
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Name | MICHELLE NASH
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Credential |
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Telephone | 612-597-3153
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | CLASS F
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License Number State | MN
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