Provider Demographics
NPI:1952459372
Name:LEGACY HOME CARE LC
Entity Type:Organization
Organization Name:LEGACY HOME CARE LC
Other - Org Name:LEGACY HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WAYDE
Authorized Official - Last Name:SONDRUP
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-888-3669
Mailing Address - Street 1:680 S PROGRESS AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2957
Mailing Address - Country:US
Mailing Address - Phone:208-888-3669
Mailing Address - Fax:208-888-3675
Practice Address - Street 1:680 S PROGRESS AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2957
Practice Address - Country:US
Practice Address - Phone:208-888-3669
Practice Address - Fax:208-888-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH-224251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806775Medicaid
137106Medicare ID - Type UnspecifiedLEGACY MCR NUMBER