Provider Demographics
NPI:1932678869
Name:RUBY JEWELLS LEGACY LLC
Entity Type:Organization
Organization Name:RUBY JEWELLS LEGACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANIQUA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-714-6562
Mailing Address - Street 1:3007 LOMBARD DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4727
Mailing Address - Country:US
Mailing Address - Phone:989-714-6562
Mailing Address - Fax:
Practice Address - Street 1:3007 LOMBARD DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4727
Practice Address - Country:US
Practice Address - Phone:989-714-6562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities