MEDICARE: LEGACY CONSUMER DIRECTED SERVICES 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	253Z00000X	In Home Supportive Care Agency	000090	MO

General Provider Information

NPI Number	:	1306277652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CONSUMER DIRECTED SERVICES LLC

Provider Business Mailing Address
First Line	:	111 W PORT PLZ
Second Line	:	600
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3011
Country	:	US
Telephone Number	:	314-478-4188
Fax Number	:	314-542-1542

Provider Business Practice Location Address
First Line	:	111 W PORT PLZ
Second Line	:	600
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3011
Country	:	US
Telephone Number	:	314-478-4188
Fax Number	:	314-542-1542

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. ZAMIKA A WALLS
Credential	:
Telephone Number	:	314-478-4188

Provider Enumeration Date	:	12/11/2013
Last Update Date	:	12/11/2013

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