Provider Demographics
NPI:1205376084
Name:LEGACY GROUP HOMES SERVICES LLC
Entity Type:Organization
Organization Name:LEGACY GROUP HOMES SERVICES LLC
Other - Org Name:LEGACY GROUP HOMES SERVICES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:FUNMILAYO
Authorized Official - Middle Name:ROSELINE
Authorized Official - Last Name:AIMILA
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:614-592-3382
Mailing Address - Street 1:2485 JOYCE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1880
Mailing Address - Country:US
Mailing Address - Phone:614-592-3382
Mailing Address - Fax:
Practice Address - Street 1:2485 JOYCE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1880
Practice Address - Country:US
Practice Address - Phone:614-592-3382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137424251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health