Provider Demographics
NPI:1023833076
Name:LEGACY AFC, LLC
Entity type:Organization
Organization Name:LEGACY AFC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTUA
Authorized Official - Suffix:
Authorized Official - Credentials:SHRM-SCP
Authorized Official - Phone:860-994-8220
Mailing Address - Street 1:120 MAPLE ST STE 401
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2208
Mailing Address - Country:US
Mailing Address - Phone:860-994-8220
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLE ST STE 401
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2208
Practice Address - Country:US
Practice Address - Phone:860-994-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency