Provider Demographics
NPI:1871159095
Name:LEGACY LIVING CENTER
Entity type:Organization
Organization Name:LEGACY LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARDA
Authorized Official - Middle Name:AVERNETTE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-290-2538
Mailing Address - Street 1:215 W RUFFIN ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2643
Mailing Address - Country:US
Mailing Address - Phone:336-290-2538
Mailing Address - Fax:
Practice Address - Street 1:215 W RUFFIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2643
Practice Address - Country:US
Practice Address - Phone:336-290-2538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health