Healthcare Provider Details

I. General information

NPI: 1427435163
Provider Name (Legal Business Name): LEGACY HEALTH CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E LOCKWOOD AVE
WEBSTER GROVES MO
63119-3050
US

IV. Provider business mailing address

5809 ITASKA ST
SAINT LOUIS MO
63109-3117
US

V. Phone/Fax

Practice location:
  • Phone: 314-200-2664
  • Fax:
Mailing address:
  • Phone: 314-971-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2006006973
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MISS CONNIE SCOTT JUSTICE
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: P.T.A.
Phone: 314-971-8626