Provider Demographics
NPI:1760915243
Name:LEGACY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-917-7998
Mailing Address - Street 1:3610 BOSQUE PLZ NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4295
Mailing Address - Country:US
Mailing Address - Phone:505-338-3702
Mailing Address - Fax:505-338-3709
Practice Address - Street 1:3610 BOSQUE PLZ NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4295
Practice Address - Country:US
Practice Address - Phone:505-338-3702
Practice Address - Fax:505-338-3709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-11
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3338251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM327211Medicare UPIN
NM321569Medicare UPIN