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General NPI Number Information
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NPI Number | 1801567938
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Entity Type | Organization
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Legal Business Name | LEGEND HOME CARE LLC
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Dates
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Enumeration Date | 09/28/2021
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Last Update Date | 09/28/2021
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Provider Practice Location Address
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Address Line | 3307 BROADWAY ST STE 150
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2387
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Country | US
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Telephone | 618-731-6550
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Fax |
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Provider Business Mailing Address
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Address Line | 15030 N TUNDRA LN
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City | MOUNT VERNON
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State | IL
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Zip | 62864-8156
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Country | US
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Telephone | 618-731-6550
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | KISCHA JACKSON
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Credential |
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Telephone | 618-731-6550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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