Provider Demographics
NPI:1477153492
Name:LEGACY HOSPICE GA, LLC
Entity Type:Organization
Organization Name:LEGACY HOSPICE GA, LLC
Other - Org Name:COASTAL HOSPICE OF GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MABERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-468-8070
Mailing Address - Street 1:101 W RENNER RD STE 420
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2022
Mailing Address - Country:US
Mailing Address - Phone:806-771-0588
Mailing Address - Fax:806-687-5966
Practice Address - Street 1:106 SHOPPERS WAY STE 111
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-0522
Practice Address - Country:US
Practice Address - Phone:912-434-9810
Practice Address - Fax:912-434-9752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003250312AMedicaid
GA11D2210199OtherCLIA
GAHSPC001445OtherSTATE OPERATOR'S LICENSE #