Provider Demographics
NPI:1851812481
Name:LEGACY HOME HEALTH AGENCY LLC
Entity Type:Organization
Organization Name:LEGACY HOME HEALTH AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:LAVERNE
Authorized Official - Last Name:RATNASWAMY
Authorized Official - Suffix:
Authorized Official - Credentials:PROVIDER
Authorized Official - Phone:407-600-8554
Mailing Address - Street 1:750 S ORANGE BLOSSOM TRL STE 116
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-3154
Mailing Address - Country:US
Mailing Address - Phone:407-906-3022
Mailing Address - Fax:
Practice Address - Street 1:750 S ORANGE BLOSSOM TRL STE 116
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-3154
Practice Address - Country:US
Practice Address - Phone:407-906-3022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL672186Medicaid