MEDICARE: LEGACY LIVING HOME CARE 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	251E00000X	Home Health Agency
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1366018046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY LIVING HOME CARE LLC

Provider Business Mailing Address
First Line	:	1828 BAINBRIDGE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 BAINBRIDGE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1807
Country	:	US
Telephone Number	:	267-602-7715
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MITCHELL EPPS
Credential	:
Telephone Number	:	267-602-7715

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	06/02/2021

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