Basic Information
| Provider Information | |||||||||
| NPI: | 1952459372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY HOME CARE LC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LEGACY HOME HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 680 S PROGRESS AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088883669 | ||||||||
| FaxNumber: | 2088883675 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 S PROGRESS AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088883669 | ||||||||
| FaxNumber: | 2088883675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SONDRUP | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | WAYDE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2088883669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HH-224 | ID | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 806775 | 05 | ID | MEDICAID |