MEDICARE: LEGACY CHARTER SCHOOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1154615243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	2422 12TH AVE RD
Second Line	:	#225
City	:	NAMPA
State	:	ID
Zip	:	83686-6300
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2422 12TH AVE RD
Second Line	:	#225
City	:	NAMPA
State	:	ID
Zip	:	83686-6300
Country	:	US
Telephone Number	:	208-466-7952
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	CELESTE BLACKBURN
Credential	:
Telephone Number	:	208-922-9300

Provider Enumeration Date	:	06/06/2011
Last Update Date	:	06/06/2011

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Directions to “LEGACY CHARTER SCHOOL ” Practice Location

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