Provider Demographics
NPI:1346693496
Name:LEGENDARY SUPPORT COORDINATION, LLC
Entity Type:Organization
Organization Name:LEGENDARY SUPPORT COORDINATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-596-5940
Mailing Address - Street 1:4950 PARKSIDE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4700
Mailing Address - Country:US
Mailing Address - Phone:215-596-5940
Mailing Address - Fax:215-921-6188
Practice Address - Street 1:4950 PARKSIDE AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4700
Practice Address - Country:US
Practice Address - Phone:215-596-5940
Practice Address - Fax:215-921-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030242230001Medicaid
PA1030242230002Medicaid