Provider Demographics
NPI:1013604180
Name:LEGACY CARE TEAM
Entity Type:Organization
Organization Name:LEGACY CARE TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEOKUK
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-433-9476
Mailing Address - Street 1:4109 CITY POINT DR STE G
Mailing Address - Street 2:
Mailing Address - City:N RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8339
Mailing Address - Country:US
Mailing Address - Phone:682-381-0595
Mailing Address - Fax:
Practice Address - Street 1:4109 CITY POINT DR STE G
Practice Address - Street 2:
Practice Address - City:N RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8339
Practice Address - Country:US
Practice Address - Phone:682-381-0595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty