Provider Demographics
NPI:1124228317
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:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:361-855-0848
Mailing Address - Street 1:6655 FIRST PARK TEN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4304
Mailing Address - Country:US
Mailing Address - Phone:210-736-1855
Mailing Address - Fax:
Practice Address - Street 1:6000 S STAPLES ST STE 403A
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2952
Practice Address - Country:US
Practice Address - Phone:361-855-0848
Practice Address - Fax:361-853-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008442251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001003937Medicaid
TX001015098Medicaid
TX001013242Medicaid
TX8616OtherCLIA
TX001003938Medicaid
TX45D0945503OtherCLIA
TX001003938Medicaid
TX8616OtherCLIA