Healthcare Provider Details

I. General information

NPI: 1528419751
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON COMMONS DR APT. 314
EVANS GA
30809-3159
US

IV. Provider business mailing address

110 HORIZON DR STE 310
RALEIGH NC
27615-4926
US

V. Phone/Fax

Practice location:
  • Phone: 706-426-8136
  • Fax: 706-496-8936
Mailing address:
  • Phone: 919-424-5080
  • Fax: 919-431-9224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM G WILSON JR.
Title or Position: CFO
Credential:
Phone: 919-424-5080