Provider Demographics
NPI:1598427353
Name:LEGACY OF WEST MEMPHIS
Entity Type:Organization
Organization Name:LEGACY OF WEST MEMPHIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-394-9133
Mailing Address - Street 1:704 CALVIN AVERY DR STE A
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6536
Mailing Address - Country:US
Mailing Address - Phone:870-394-9133
Mailing Address - Fax:
Practice Address - Street 1:704 CALVIN AVERY DR STE A
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-6536
Practice Address - Country:US
Practice Address - Phone:870-394-9133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty