Provider Demographics
NPI:1689652166
Name:LEGACY HOME HEALTH AGENCY, INC.
Entity Type:Organization
Organization Name:LEGACY HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:361-855-0848
Mailing Address - Street 1:6655 FIRST PARK TEN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4304
Mailing Address - Country:US
Mailing Address - Phone:210-736-1855
Mailing Address - Fax:
Practice Address - Street 1:6000 S STAPLES ST STE 403A
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2952
Practice Address - Country:US
Practice Address - Phone:361-855-0848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008442251E00000X
008442251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX024409701Medicaid
TX0244097-01Medicaid
TX1003937Medicaid
TX1003938Medicaid
TX001015098Medicaid
TX1003935Medicaid
TX45D0945503OtherCLIA
TX1003937Medicaid
TX1003938Medicaid
TX001015098Medicaid