=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700690856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING LEGACY ADULT DAY HEALTH PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 E KING ST
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28501-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-408-8330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1004 E BRIGHT ST
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28501-5720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-408-8330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LATEEFAH KHADEJAH IRVINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-393-5188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------