Organization
LEGACY VILLAGE OUTPATIENT ID, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DENNIS SCOTT FARMER (CHIEF EXECUTIVE OFFICER)
(800) 997-6977
Entity
Organization
Contact information
Practice address
800 W MAIN ST STE 1460, BOISE, ID 83702-5983
(800) 997-6977
(661) 489-0573
Mailing address
800 W MAIN ST STE 1460, BOISE, ID 83702-5983
(800) 997-6977
(661) 489-0573
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
05/31/2023
Last updated
05/31/2023
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