Provider Demographics
NPI:1730890047
Name:LEGACY HOUSE COMMUNITY SERVICE
Entity type:Organization
Organization Name:LEGACY HOUSE COMMUNITY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-215-6101
Mailing Address - Street 1:11747 N 19TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3590
Mailing Address - Country:US
Mailing Address - Phone:901-215-6101
Mailing Address - Fax:
Practice Address - Street 1:11747 N 19TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-3590
Practice Address - Country:US
Practice Address - Phone:901-215-6101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health