Provider Demographics
NPI:1528704640
Name:LEGENDARY FAMILY CARE COMPANY LLC
Entity type:Organization
Organization Name:LEGENDARY FAMILY CARE COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-731-9004
Mailing Address - Street 1:263 W BOBCAT CT
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1043
Mailing Address - Country:US
Mailing Address - Phone:414-731-9004
Mailing Address - Fax:
Practice Address - Street 1:263 W BOBCAT CT
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1043
Practice Address - Country:US
Practice Address - Phone:414-731-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7573OtherAZ DEPARTMENT OF HEALTH SERVICES