Provider Demographics
NPI:1538490974
Name:LEGACY CARE PROVIDERS INC
Entity Type:Organization
Organization Name:LEGACY CARE PROVIDERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT / BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:TAMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-847-0617
Mailing Address - Street 1:175 80TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:CLARA CITY
Mailing Address - State:MN
Mailing Address - Zip Code:56222-1221
Mailing Address - Country:US
Mailing Address - Phone:320-841-0617
Mailing Address - Fax:320-875-4555
Practice Address - Street 1:116 SCHAAF ST
Practice Address - Street 2:
Practice Address - City:MURDOCK
Practice Address - State:MN
Practice Address - Zip Code:56271-7995
Practice Address - Country:US
Practice Address - Phone:320-875-4742
Practice Address - Fax:320-875-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN347574310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN347574OtherASSISTED LIVING CLASS F HOME CARE PROVIDER