Provider Demographics
NPI:1003506171
Name:LEGACY RESIDENTIAL PROGRAM
Entity type:Organization
Organization Name:LEGACY RESIDENTIAL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:215-397-7823
Mailing Address - Street 1:8480 LIMEKILN PIKE PH 5
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-2816
Mailing Address - Country:US
Mailing Address - Phone:267-315-5124
Mailing Address - Fax:
Practice Address - Street 1:2156 N 30TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-1101
Practice Address - Country:US
Practice Address - Phone:267-315-5124
Practice Address - Fax:267-324-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1366151854Medicaid
PA1386342533Medicaid