Provider Demographics
NPI:1922277706
Name:LEGACY HUMAN SERVICES, INC.
Entity Type:Organization
Organization Name:LEGACY HUMAN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-438-6700
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-0088
Mailing Address - Country:US
Mailing Address - Phone:252-438-6700
Mailing Address - Fax:252-438-6720
Practice Address - Street 1:605 N COUNTRY CLUB DR
Practice Address - Street 2:OXFORD GROUP HOME
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2848
Practice Address - Country:US
Practice Address - Phone:919-693-1694
Practice Address - Fax:252-438-6720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL- 039 -029311ZA0620X
NCMHL-039-029320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805488Medicaid