Provider Demographics
NPI:1225563976
Name:LEGACY HOME HEALTH, INC.
Entity Type:Organization
Organization Name:LEGACY HOME HEALTH, INC.
Other - Org Name:PLEXUS HEALTHCARE INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/DPCS
Authorized Official - Prefix:
Authorized Official - First Name:MACEDONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:562-858-1861
Mailing Address - Street 1:7365 CARNELIAN ST
Mailing Address - Street 2:116A
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1158
Mailing Address - Country:US
Mailing Address - Phone:909-608-7566
Mailing Address - Fax:909-608-7567
Practice Address - Street 1:7365 CARNELIAN ST
Practice Address - Street 2:116A
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1158
Practice Address - Country:US
Practice Address - Phone:909-608-7566
Practice Address - Fax:909-296-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000450251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922279694Medicaid
CA1922279694Medicaid