Provider Demographics
NPI:1083590640
Name:LEGACY FAMILY ENTERTAINMENT
Entity type:Organization
Organization Name:LEGACY FAMILY ENTERTAINMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-937-5770
Mailing Address - Street 1:211 PROVIDENCE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-4687
Mailing Address - Country:US
Mailing Address - Phone:757-937-5563
Mailing Address - Fax:
Practice Address - Street 1:211 PROVIDENCE RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-4687
Practice Address - Country:US
Practice Address - Phone:757-937-5563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-11
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3001824809Medicaid
VA30018248090001Medicaid