Basic Information
| Provider Information | |||||||||
| NPI: | 1861795254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY HOME HEALTHCARE OF SOUTHERN ARIZONA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEGACY HEALTH CARE HOME SUPPORTIVE SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 S HWY 92 STE A | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856355836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203356118 | ||||||||
| FaxNumber: | 5203356736 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 S HWY 92 STE A | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856355836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203356118 | ||||||||
| FaxNumber: | 5203356736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 12/07/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LADD | ||||||||
| AuthorizedOfficialFirstName: | SHELLA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5203356118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, BSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.