Healthcare Provider Details

I. General information

NPI: 1689141376
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 E BELVIDERE RD
GRAYSLAKE IL
60030-2218
US

IV. Provider business mailing address

110 HORIZON DR STE 310
RALEIGH NC
27615-4926
US

V. Phone/Fax

Practice location:
  • Phone: 919-424-4312
  • Fax:
Mailing address:
  • Phone: 919-424-5080
  • Fax: 919-431-9224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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