Provider Demographics
NPI:1760617245
Name:LEGACY VILLAGE GREENHOUSE CORP
Entity Type:Organization
Organization Name:LEGACY VILLAGE GREENHOUSE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GUIDE
Authorized Official - Prefix:MS
Authorized Official - First Name:CRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GINTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-271-2387
Mailing Address - Street 1:1303 NE LEGACY PKWY
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4940
Mailing Address - Country:US
Mailing Address - Phone:479-271-2387
Mailing Address - Fax:479-273-5883
Practice Address - Street 1:1303 NE LEGACY PKWY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4940
Practice Address - Country:US
Practice Address - Phone:479-271-2387
Practice Address - Fax:479-273-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR038310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175718794Medicaid