# LEGACY LODGE AT JACKSON HOLE, INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1760927453
- **Authorized official:** JASON HARNISCH (VP OF FINANCE)
- **Authorized official phone:** (402) 753-6101

## Contact information

- **Practice address:** 3000 W BIG TRAIL DR, JACKSON, WY 83001-9138
- **Practice address phone:** (307) 734-0500
- **Mailing address:** 2230 N SOMERS AVE, FREMONT, NE 68025-2515

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 310400000X | Assisted Living Facility | — | WY | Yes |

## Other

- **Enumeration date:** 01/04/2017
- **Last updated:** 01/04/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | PENDING | — | WY |