MEDICARE: LEGACY SUPPORT 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	:	1467331850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY SUPPORT LLC

Provider Business Mailing Address
First Line	:	2913 RICE CREEK PKWY NE
Second Line	:
City	:	BLAINE
State	:	MN
Zip	:	55449-6766
Country	:	US
Telephone Number	:	763-219-0826
Fax Number	:

Provider Business Practice Location Address
First Line	:	2913 RICE CREEK PKWY NE
Second Line	:
City	:	BLAINE
State	:	MN
Zip	:	55449-6766
Country	:	US
Telephone Number	:	763-219-0826
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ABDETA TULA
Credential	:
Telephone Number	:	612-229-1635

Provider Enumeration Date	:	08/29/2025
Last Update Date	:	08/29/2025

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