Provider Demographics
NPI:1104823038
Name:LEGACY HOSPICE CARE, LLC
Entity Type:Organization
Organization Name:LEGACY HOSPICE CARE, LLC
Other - Org Name:LEGACY HOME HEALTH AND HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-895-8686
Mailing Address - Street 1:680 S PROGRESS AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2958
Mailing Address - Country:US
Mailing Address - Phone:208-895-8686
Mailing Address - Fax:208-895-8975
Practice Address - Street 1:680 S PROGRESS AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2957
Practice Address - Country:US
Practice Address - Phone:208-895-8686
Practice Address - Fax:208-895-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID131546Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ID1104823038Medicare ID - Type UnspecifiedMEDICARE PROVIDER