Provider Demographics
NPI:1376123356
Name:LEGACY CARE SOURCE
Entity Type:Organization
Organization Name:LEGACY CARE SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VERANDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:205-792-3690
Mailing Address - Street 1:11073 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35456-2213
Mailing Address - Country:US
Mailing Address - Phone:205-792-3690
Mailing Address - Fax:
Practice Address - Street 1:11073 LEXINGTON DR
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:AL
Practice Address - Zip Code:35456-2213
Practice Address - Country:US
Practice Address - Phone:205-792-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care