Provider Demographics
NPI:1295185841
Name:LEGACY VILLAGE, LLC
Entity Type:Organization
Organization Name:LEGACY VILLAGE, LLC
Other - Org Name:OREGON STREET RECOVERY CENTER
Other - Org Type:Doing Business As
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:805-792-3595
Mailing Address - Street 1:230 HANS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-5025
Mailing Address - Country:US
Mailing Address - Phone:805-792-3595
Mailing Address - Fax:661-489-0573
Practice Address - Street 1:230 HANS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-5025
Practice Address - Country:US
Practice Address - Phone:805-792-3595
Practice Address - Fax:661-489-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA150071APOtherRESIDENTIAL TREATMENT LICENSE