Provider Demographics
NPI:1457932394
Name:LEGACY EMPOWERMENT SERVICES LLC
Entity Type:Organization
Organization Name:LEGACY EMPOWERMENT SERVICES LLC
Other - Org Name:LEGACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-523-0769
Mailing Address - Street 1:110 FIELDCREST AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3648
Mailing Address - Country:US
Mailing Address - Phone:732-523-0769
Mailing Address - Fax:848-228-3148
Practice Address - Street 1:110 FIELDCREST AVE STE 3
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3648
Practice Address - Country:US
Practice Address - Phone:732-523-0769
Practice Address - Fax:848-228-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0748579Medicaid