Provider Demographics
NPI:1760085542
Name:LEGACY MEMORY CARE AT KINSTON, LLC
Entity Type:Organization
Organization Name:LEGACY MEMORY CARE AT KINSTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATEEFAH
Authorized Official - Middle Name:KHADEJAH
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-393-5188
Mailing Address - Street 1:3532 LENA LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-6163
Mailing Address - Country:US
Mailing Address - Phone:973-393-5188
Mailing Address - Fax:252-527-0433
Practice Address - Street 1:1406 E SHINE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-5836
Practice Address - Country:US
Practice Address - Phone:252-527-0438
Practice Address - Fax:252-527-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home