MEDICARE: CRESTWOOD LEGACY HOMES 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1215863352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWOOD LEGACY HOMES LLC

Provider Business Mailing Address
First Line	:	942 STUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43206-1637
Country	:	US
Telephone Number	:	937-543-2738
Fax Number	:

Provider Business Practice Location Address
First Line	:	942 STUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43206-1637
Country	:	US
Telephone Number	:	937-543-2738
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL SIMBARASHE SHENJERE MUTISWA
Credential	:
Telephone Number	:	937-543-2738

Provider Enumeration Date	:	06/18/2026
Last Update Date	:	06/18/2026

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