Provider Demographics
NPI:1316302367
Name:LEGACY IL OPERATING CO, LLC
Entity type:Organization
Organization Name:LEGACY IL OPERATING CO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:RENOID
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-360-8785
Mailing Address - Street 1:6539 KNIGHT ARNOLD ROAD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-0697
Mailing Address - Country:US
Mailing Address - Phone:901-360-8785
Mailing Address - Fax:
Practice Address - Street 1:6539 KNIGHT ARNOLD ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-0697
Practice Address - Country:US
Practice Address - Phone:901-360-8785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility