Provider Demographics
NPI:1073329462
Name:LEGACY 12 HOLDINGS, LLC.
Entity type:Organization
Organization Name:LEGACY 12 HOLDINGS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGOSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:304-541-3031
Mailing Address - Street 1:325 LONG COVE TRL
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:SC
Mailing Address - Zip Code:29676-3920
Mailing Address - Country:US
Mailing Address - Phone:304-541-3031
Mailing Address - Fax:
Practice Address - Street 1:144 THOMAS GREEN BLVD STE 239
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2291
Practice Address - Country:US
Practice Address - Phone:304-541-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME MATTERS CAREGIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care