Provider Demographics
NPI:1922496926
Name:LEGACY HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:518-320-5715
Mailing Address - Street 1:28 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-2431
Mailing Address - Country:US
Mailing Address - Phone:518-320-5715
Mailing Address - Fax:
Practice Address - Street 1:28 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-2431
Practice Address - Country:US
Practice Address - Phone:518-320-5715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5480310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility