Provider Demographics
NPI:1760204630
Name:LEGACY HOSPICE OF SOUTH GA, LLC
Entity type:Organization
Organization Name:LEGACY HOSPICE OF SOUTH GA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MABERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-468-8070
Mailing Address - Street 1:101 W RENNER RD STE 420
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2022
Mailing Address - Country:US
Mailing Address - Phone:214-550-3306
Mailing Address - Fax:
Practice Address - Street 1:205 S TALLAHASSEE ST STE A
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6025
Practice Address - Country:US
Practice Address - Phone:912-527-8602
Practice Address - Fax:912-527-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based