Provider Demographics
NPI:1245742626
Name:MK LEGACY
Entity Type:Organization
Organization Name:MK LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-203-1892
Mailing Address - Street 1:422 E VERMIJO AVE STE G16
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3791
Mailing Address - Country:US
Mailing Address - Phone:719-203-1892
Mailing Address - Fax:
Practice Address - Street 1:422 E VERMIJO AVE STE G16
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3791
Practice Address - Country:US
Practice Address - Phone:719-203-1892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services