=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689597486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY DREAM HOUSE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2026
-----------------------------------------------------
Last Update Date | 07/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 MIMOSA DR
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-546-6049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 MIMOSA DR
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-546-6049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DARRENTON K HARRIS SR.
-----------------------------------------------------
Credential | BBA,MBA
-----------------------------------------------------
Telephone | 386-546-6049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------