Healthcare Provider Details

I. General information

NPI: 1942842919
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 PERKINS RD
PALMETTO GA
30268-2374
US

IV. Provider business mailing address

3001 SPRING FOREST RD STE 101
RALEIGH NC
27616-2816
US

V. Phone/Fax

Practice location:
  • Phone: 770-463-2460
  • Fax:
Mailing address:
  • Phone: 919-424-4312
  • 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: WILLIAM G WILSON JR.
Title or Position: CHIEF FINANCIAL OFFICE
Credential:
Phone: 919-424-5080