Provider Demographics
NPI:1972155836
Name:LEGACY PRIVATE HOME CARE SERVICES
Entity Type:Organization
Organization Name:LEGACY PRIVATE HOME CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLAYINKA
Authorized Official - Middle Name:
Authorized Official - Last Name:OYEDOTUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-755-4074
Mailing Address - Street 1:2302 PARKLAKE DR NE STE 578
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2896
Mailing Address - Country:US
Mailing Address - Phone:310-755-4045
Mailing Address - Fax:
Practice Address - Street 1:2302 PARKLAKE DR NE STE 578
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2896
Practice Address - Country:US
Practice Address - Phone:310-755-4045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health