Provider Demographics
NPI:1003019233
Name:LEGACY ACTIVE LIVING RETIREMENT COMMUNITY
Entity Type:Organization
Organization Name:LEGACY ACTIVE LIVING RETIREMENT COMMUNITY
Other - Org Name:LEGACY POINTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-341-0911
Mailing Address - Street 1:1020 SOUTH SCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240
Mailing Address - Country:US
Mailing Address - Phone:319-341-0911
Mailing Address - Fax:
Practice Address - Street 1:1020 S SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-2944
Practice Address - Country:US
Practice Address - Phone:319-341-0911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0116310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0277046Medicaid