Basic Information
| Provider Information | |||||||||
| NPI: | 1780737692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERWOOD HEALTHCARE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 BACON ST | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778642511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363489097 | ||||||||
| FaxNumber: | 9363489212 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 BACON ST | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778642511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363489097 | ||||||||
| FaxNumber: | 9363489212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MANAGEMENT COMPANY | ||||||||
| AuthorizedOfficialTelephone: | 7706190866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 116849 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5342 | 05 | TX | MEDICAID |