Provider Demographics
NPI:1801467758
Name:LEGACY HOSPICE OF COLORADO SPRINGS, LLC
Entity type:Organization
Organization Name:LEGACY HOSPICE OF COLORADO SPRINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9601
Mailing Address - Country:US
Mailing Address - Phone:704-662-0416
Mailing Address - Fax:
Practice Address - Street 1:1320 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2082
Practice Address - Country:US
Practice Address - Phone:719-543-7847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY HOSPICE OF COLORADO SPRINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000156111Medicaid