Provider Demographics
NPI:1275225310
Name:LEGACY VILLAGE HQ, LLC
Entity Type:Organization
Organization Name:LEGACY VILLAGE HQ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-997-6977
Mailing Address - Street 1:800 W MAIN ST STE 1460
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5983
Mailing Address - Country:US
Mailing Address - Phone:800-997-6977
Mailing Address - Fax:661-489-0573
Practice Address - Street 1:800 W MAIN ST STE 1460
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5983
Practice Address - Country:US
Practice Address - Phone:800-997-6977
Practice Address - Fax:661-489-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)