Provider Demographics
NPI:1003970104
Name:LEGACY HEALTHCARE PROVIDERS, INC.
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE PROVIDERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIEGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CACHO
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:626-858-5611
Mailing Address - Street 1:1272 CENTER COURT DR
Mailing Address - Street 2:STE. 203
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3667
Mailing Address - Country:US
Mailing Address - Phone:626-858-5611
Mailing Address - Fax:626-858-5614
Practice Address - Street 1:1272 CENTER COURT DR
Practice Address - Street 2:STE. 203
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3667
Practice Address - Country:US
Practice Address - Phone:626-858-5611
Practice Address - Fax:626-858-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980001464251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058207Medicare ID - Type Unspecified