Provider Demographics
NPI:1447635289
Name:LEGACY HOME HEALTH CARE OF SOUTHERN ARIZONA, LLC
Entity type:Organization
Organization Name:LEGACY HOME HEALTH CARE OF SOUTHERN ARIZONA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:928-632-2373
Mailing Address - Street 1:4996 E MEDITERRANEAN DR
Mailing Address - Street 2:STE D
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2435
Mailing Address - Country:US
Mailing Address - Phone:520-335-6118
Mailing Address - Fax:
Practice Address - Street 1:1491 W THATCHER BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3362
Practice Address - Country:US
Practice Address - Phone:520-335-6118
Practice Address - Fax:888-504-1425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY HOME HEALTH CARE OF SOUTHERN ARIZONA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-22
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA7638251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZHHA7638OtherSTATE HOME HEALTH CARE LICENSE