Provider Demographics
NPI:1033319223
Name:LEGACY HOME HEALTH AGENCY, INC.
Entity Type:Organization
Organization Name:LEGACY HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-855-0848
Mailing Address - Street 1:5277 OLD BROWNSVILLE RD
Mailing Address - Street 2:SUTIE 205
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-3929
Mailing Address - Country:US
Mailing Address - Phone:361-855-0848
Mailing Address - Fax:631-854-6795
Practice Address - Street 1:213 E FERGUSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-1826
Practice Address - Country:US
Practice Address - Phone:956-787-9947
Practice Address - Fax:956-787-1779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY HOME HEALTH AGENCY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-25
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008442251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1003938Medicaid
TX1015098Medicaid
TX1003937Medicaid
TX8616OtherCLIA
TX459433Medicare PIN
TX1003937Medicaid