Provider Demographics
NPI:1639954621
Name:MARY'S LEGACY HOMES, LLC
Entity Type:Organization
Organization Name:MARY'S LEGACY HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHALETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:334-412-1418
Mailing Address - Street 1:1803 SHOREHAM DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2716
Mailing Address - Country:US
Mailing Address - Phone:334-412-1418
Mailing Address - Fax:334-593-0376
Practice Address - Street 1:5842 SANROCK TERRACE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-6550
Practice Address - Country:US
Practice Address - Phone:334-593-5173
Practice Address - Fax:334-593-0376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities