Provider Demographics
NPI:1962746842
Name:LEGACY LIFE CARE PROGRAMS
Entity type:Organization
Organization Name:LEGACY LIFE CARE PROGRAMS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NHA MPS/IMFT
Authorized Official - Phone:931-215-2182
Mailing Address - Street 1:100 N. BIGBY DR.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4704
Mailing Address - Country:US
Mailing Address - Phone:931-215-2182
Mailing Address - Fax:931-381-5363
Practice Address - Street 1:1324 TROTWOOD AVE STE 11
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4750
Practice Address - Country:US
Practice Address - Phone:931-626-1644
Practice Address - Fax:931-381-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000018345101YM0800X, 251V00000X, 251V00000X
TN10000000113781041C0700X, 251S00000X, 1041C0700X, 251S00000X, 253Z00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1437420742Medicaid
TNNPI 1265768428OtherSUPERVISOR
TNQ006613Medicaid
TN1962746842OtherGROUP NPI
TN1225450802OtherINDIVIDUAL PROVIDER NPI
TN1669548608OtherSUPERVISING PROVIDER NPI
TNH445654Medicaid
TNQ010864Medicaid