Basic Information
| Provider Information | |||||||||
| NPI: | 1770781114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY HEALTH AND REHABILITATION OF PLEASANT GROVE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351271962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057448226 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351271962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057448226 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | CODY | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2053913600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N3748 | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 013348 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 4758210S | 05 | AL | MEDICAID |