Provider Demographics
NPI: | 1003506171 |
---|---|
Name: | LEGACY RESIDENTIAL PROGRAM |
Entity Type: | Organization |
Organization Name: | LEGACY RESIDENTIAL PROGRAM |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | ASHLEY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | EDWARDS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RN |
Authorized Official - Phone: | 215-397-7823 |
Mailing Address - Street 1: | 8480 LIMEKILN PIKE PH 5 |
Mailing Address - Street 2: | |
Mailing Address - City: | WYNCOTE |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19095-2816 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 267-315-5124 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2156 N 30TH ST |
Practice Address - Street 2: | |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19121-1101 |
Practice Address - Country: | US |
Practice Address - Phone: | 267-315-5124 |
Practice Address - Fax: | 267-324-3106 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-05-11 |
Last Update Date: | 2023-05-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251B00000X | Agencies | Case Management | |
No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
No | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities | |
No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
No | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | |
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DE | 1366151854 | Medicaid | |
PA | 1386342533 | Medicaid |