Provider Demographics
NPI:1538020607
Name:LEGACY GRACE SUPPORT SERVICES LLC NO
Entity type:Organization
Organization Name:LEGACY GRACE SUPPORT SERVICES LLC NO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TAKILA
Authorized Official - Middle Name:K
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-373-3835
Mailing Address - Street 1:26632 YALE ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2546
Mailing Address - Country:US
Mailing Address - Phone:734-373-3835
Mailing Address - Fax:
Practice Address - Street 1:26632 YALE ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2546
Practice Address - Country:US
Practice Address - Phone:734-373-3835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-19
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health