Provider Demographics
NPI:1245796721
Name:LEGACY HOUSE OF CARING
Entity Type:Organization
Organization Name:LEGACY HOUSE OF CARING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:DUBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-492-6253
Mailing Address - Street 1:540 BROOK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9611
Mailing Address - Country:US
Mailing Address - Phone:320-492-6253
Mailing Address - Fax:
Practice Address - Street 1:2428 IMPERIAL DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5009
Practice Address - Country:US
Practice Address - Phone:320-251-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA502690100OtherSTATE OF MINNESOTA