Provider Demographics
NPI:1760100697
Name:SOUTHERN LEGACY HOSPICE LLC
Entity Type:Organization
Organization Name:SOUTHERN LEGACY HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:MR
Authorized Official - First Name:SAJID
Authorized Official - Middle Name:H
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:213-550-7205
Mailing Address - Street 1:616 FM 1960 RD W STE 575
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3042
Mailing Address - Country:US
Mailing Address - Phone:213-550-7205
Mailing Address - Fax:
Practice Address - Street 1:616 FM 1960 RD W STE 575
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3042
Practice Address - Country:US
Practice Address - Phone:213-550-7205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty