Provider Demographics
NPI:1104860428
Name:LEGACY HOSPICE OF THE EAST, LLC
Entity Type:Organization
Organization Name:LEGACY HOSPICE OF THE EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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 1:951 US HIGHWAY 80 WEST
Practice Address - Street 2:SUITE D
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-218-1826
Practice Address - Fax:334-218-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11621251G00000X
251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC 1604EMedicaid
AL011604Medicare ID - Type Unspecified