Healthcare Provider Details

I. General information

NPI: 1467073189
Provider Name (Legal Business Name): LEGACY HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 PARKER RD SE STE 210
CONYERS GA
30094-6654
US

IV. Provider business mailing address

1775 PARKER RD SE STE 210
CONYERS GA
30094-6654
US

V. Phone/Fax

Practice location:
  • Phone: 707-731-7700
  • Fax:
Mailing address:
  • Phone: 707-731-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONNETTE FRANK
Title or Position: CHIEF COMPLIANCE OFFICER
Credential: RN
Phone: 770-731-7700