Provider Demographics
NPI:1376712067
Name:LEGACY HUMAN SERVICES, INC.
Entity Type:Organization
Organization Name:LEGACY HUMAN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-438-6700
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-0088
Mailing Address - Country:US
Mailing Address - Phone:252-438-6700
Mailing Address - Fax:
Practice Address - Street 1:663 MOULTON RD
Practice Address - Street 2:FRANKLIN COUNTY GROUP HOME #1
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-7753
Practice Address - Country:US
Practice Address - Phone:919-496-6377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL-035-035311ZA0620X
NC7804378320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805493Medicaid