Provider Demographics
NPI:1033238233
Name:LEGACY HOSPICE LLC
Entity Type:Organization
Organization Name:LEGACY HOSPICE LLC
Other - Org Name:LEGACY HOSPICE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:205-652-6167
Mailing Address - Street 1:PO BOX 2130
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-2130
Mailing Address - Country:US
Mailing Address - Phone:334-686-0138
Mailing Address - Fax:205-652-9110
Practice Address - Street 1:607 BILLINGTON ST # B
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857
Practice Address - Country:US
Practice Address - Phone:573-888-4946
Practice Address - Fax:573-888-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133-3H0251G00000X
251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO826132102Medicaid