Healthcare Provider Details

I. General information

NPI: 1992381040
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10061 SWEETWATER PKWY
JACKSONVILLE FL
32256-3977
US

IV. Provider business mailing address

3001 SPRING FOREST RD
RALEIGH NC
27616-2815
US

V. Phone/Fax

Practice location:
  • Phone: 855-239-3467
  • Fax:
Mailing address:
  • Phone: 910-724-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM GIL WILSON JR.
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 919-424-5080