Provider Demographics
NPI:1831196328
Name:LEGACY HEALTH CARE, INC.
Entity type:Organization
Organization Name:LEGACY HEALTH CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-771-9099
Mailing Address - Street 1:3135 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-8832
Mailing Address - Country:US
Mailing Address - Phone:801-771-9099
Mailing Address - Fax:801-771-0200
Practice Address - Street 1:3135 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8832
Practice Address - Country:US
Practice Address - Phone:801-771-9099
Practice Address - Fax:801-771-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-HOSPICE-55836251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid