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General NPI Number Information
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NPI Number | 1952459372
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Entity Type | Organization
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Legal Business Name | LEGACY HOME CARE LC
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 08/07/2007
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Provider Practice Location Address
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Address Line | 680 S PROGRESS AVE SUITE 2A
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City | MERIDIAN
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State | ID
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Zip | 83642-2957
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Country | US
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Telephone | 208-888-3669
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Fax | 208-888-3675
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Provider Business Mailing Address
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Address Line | 680 S PROGRESS AVE SUITE 2A
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City | MERIDIAN
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State | ID
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Zip | 83642-2957
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Country | US
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Telephone | 208-888-3669
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Fax | 208-888-3675
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Authorized Official
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Title or Position | OWNER ADMINISTRATOR
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Name | MR. ROGER WAYDE SONDRUP
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Credential | PT
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Telephone | 208-888-3669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | HH-224
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License Number State | ID
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