MEDICARE: LEGACY HOSPICE CARES LLC

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1184136939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HOSPICE CARES LLC

Provider Business Mailing Address
First Line	:	850 ELM GROVE RD STE 21
Second Line	:
City	:	ELM GROVE
State	:	WI
Zip	:	53122-2527
Country	:	US
Telephone Number	:	262-716-6802
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 ELM GROVE RD STE 21
Second Line	:
City	:	ELM GROVE
State	:	WI
Zip	:	53122-2527
Country	:	US
Telephone Number	:	262-716-6802
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KARIN JOHNSON
Credential	:
Telephone Number	:	262-716-6802

Provider Enumeration Date	:	11/02/2017
Last Update Date	:	11/02/2017

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