MEDICARE: LEGACY FAMILY 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	1212-01-001	VA

General Provider Information

NPI Number	:	1417260357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY FAMILY SERVICES, LLC

Provider Business Mailing Address
First Line	:	6033 BONNEAU RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-2008
Country	:	US
Telephone Number	:	804-908-7374
Fax Number	:	804-354-6006

Provider Business Practice Location Address
First Line	:	8385 CARDOVA CIR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-1548
Country	:	US
Telephone Number	:	804-908-7374
Fax Number	:	804-354-6006

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MRS. TANYA JUDON-WINSTON
Credential	:
Telephone Number	:	804-908-7374

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	07/20/2010

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