Provider Demographics
NPI:1104384510
Name:LEGACY SKILL NURSING L.L.C.
Entity Type:Organization
Organization Name:LEGACY SKILL NURSING L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-607-2574
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-0246
Mailing Address - Country:US
Mailing Address - Phone:787-719-7878
Mailing Address - Fax:
Practice Address - Street 1:908 CALLE VICTORIA
Practice Address - Street 2:BARIO TEJAS
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-719-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR417856OtherSTATE DEPARTMENT