Provider Demographics
NPI:1033238241
Name:LEGACY HOSPICE, LLC
Entity Type:Organization
Organization Name:LEGACY HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:901 WEST KEISER AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370
Practice Address - Country:US
Practice Address - Phone:870-563-9995
Practice Address - Fax:870-563-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4223251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11568OtherBCBS PROVIDER #
AR154572747Medicaid