Provider Demographics
NPI:1861852618
Name:LEGACY HOME HEALTHCARE LLC
Entity Type:Organization
Organization Name:LEGACY HOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ONTARIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-460-7971
Mailing Address - Street 1:6410 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2015
Mailing Address - Country:US
Mailing Address - Phone:414-930-0464
Mailing Address - Fax:414-930-0493
Practice Address - Street 1:6410 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2015
Practice Address - Country:US
Practice Address - Phone:414-930-0464
Practice Address - Fax:414-930-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054125Medicaid