Healthcare Provider Details

I. General information

NPI: 1306730635
Provider Name (Legal Business Name): LEGACY CENTER FOR BIRTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S BLACKBIRD ROOST
FLAGSTAFF AZ
86001-6296
US

IV. Provider business mailing address

555 S BLACKBIRD ROOST
FLAGSTAFF AZ
86001-6296
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-6064
  • Fax: 928-773-9694
Mailing address:
  • Phone: 928-779-6064
  • Fax: 928-773-9694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL HARRIS
Title or Position: OFFICE MANAGER
Credential: CPM
Phone: 928-779-6064