Provider Demographics
NPI:1255510889
Name:LEGACY SENIOR SERVICES
Entity type:Organization
Organization Name:LEGACY SENIOR SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-695-5618
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:FRAZEE
Mailing Address - State:MN
Mailing Address - Zip Code:56544-0096
Mailing Address - Country:US
Mailing Address - Phone:218-334-4501
Mailing Address - Fax:218-334-4500
Practice Address - Street 1:219 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FRAZEE
Practice Address - State:MN
Practice Address - Zip Code:56544-4346
Practice Address - Country:US
Practice Address - Phone:218-334-4501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN337844314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4980495OtherMEDICA WAIVER
MN7122681OtherMEDICA INSURANCE
MN5L06FROtherBLUECROSS BLUESHIELD
MN7100395OtherMEDICA MSHO
MN80314OtherUNICARE
MN972153000Medicaid
MN245299Medicare Oscar/Certification