Provider Demographics
NPI:1285757187
Name:LEGACY HOUSE
Entity type:Organization
Organization Name:LEGACY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:I
Authorized Official - Last Name:NERVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-467-0911
Mailing Address - Street 1:190 WHITMORE LN
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6932
Mailing Address - Country:US
Mailing Address - Phone:707-467-0911
Mailing Address - Fax:
Practice Address - Street 1:6893 HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-9526
Practice Address - Country:US
Practice Address - Phone:530-365-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness