Basic Information
| Provider Information | |||||||||
| NPI: | 1801467758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY HOSPICE OF COLORADO SPRINGS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 BRAWLEY SCHOOL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046620416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1320 FORTINO BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195437847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2021 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7046642876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEGACY HOSPICE OF COLORADO SPRINGS, LLC | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 9000156111 | 05 | CO | MEDICAID |