Provider Demographics
NPI:1831113463
Name:LEGACY HEALTHCARE CORP
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-478-5953
Mailing Address - Street 1:485 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-5541
Mailing Address - Country:US
Mailing Address - Phone:423-478-5953
Mailing Address - Fax:423-472-6283
Practice Address - Street 1:600 BACON ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-2511
Practice Address - Country:US
Practice Address - Phone:936-348-9097
Practice Address - Fax:936-348-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116849314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5342Medicaid
TX675481Medicare ID - Type Unspecified