Provider Demographics
NPI:1801385505
Name:MARIANNE'S LEGACY HOME, LLC
Entity Type:Organization
Organization Name:MARIANNE'S LEGACY HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CARTLYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:516-902-7088
Mailing Address - Street 1:4406 W COPLEN FARMS RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-7131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23515 VALDERAMA LN
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-6937
Practice Address - Country:US
Practice Address - Phone:516-902-7088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities