Provider Demographics
NPI:1881866499
Name:LEGACY VILLAGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:LEGACY VILLAGE HEALTHCARE LLC
Other - Org Name:LEGACY VILLAGE FOR REHABILITATION & MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAIRHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-269-0700
Mailing Address - Street 1:1018 ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-3470
Mailing Address - Country:US
Mailing Address - Phone:801-269-0700
Mailing Address - Fax:801-269-1512
Practice Address - Street 1:5472 S 3200 W
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-7804
Practice Address - Country:US
Practice Address - Phone:801-269-0700
Practice Address - Fax:801-269-1512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN STATES LODGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-24
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTTO BE DETERMINED311500000X
UTTO BE DETERMINED314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT800008673001Medicaid
UT113661303001Medicaid
UT870520717001Medicaid
UT870638970001Medicaid
UT465171Medicare Oscar/Certification