Provider Demographics
NPI:1417727314
Name:LEGACY RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:LEGACY RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUKUNDO
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:646-331-4597
Mailing Address - Street 1:20 GARFIELD ST APT 11
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-2412
Mailing Address - Country:US
Mailing Address - Phone:646-331-4597
Mailing Address - Fax:
Practice Address - Street 1:20 GARFIELD ST APT 11
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-2412
Practice Address - Country:US
Practice Address - Phone:646-331-4597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities