Provider Demographics
NPI:1255145611
Name:LEGACY HEALTH SERVICES LLC
Entity type:Organization
Organization Name:LEGACY HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLAWALE
Authorized Official - Middle Name:SUNDAY
Authorized Official - Last Name:FAKUADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-702-2547
Mailing Address - Street 1:16003 E 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-8723
Mailing Address - Country:US
Mailing Address - Phone:317-702-2547
Mailing Address - Fax:
Practice Address - Street 1:16003 E 107TH AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-8723
Practice Address - Country:US
Practice Address - Phone:317-702-2547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services