Basic Information
| Provider Information | |||||||||
| NPI: | 1396114054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY ON 10TH OPCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEGACY ON 10TH AVENUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 N CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606475203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127248950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2015 SE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666071615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853130946 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOLE | ||||||||
| AuthorizedOfficialFirstName: | ISAAC | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3127248950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.