Healthcare Provider Details

I. General information

NPI: 1154247310
Provider Name (Legal Business Name): LEGACY PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11005 COVINGTON WAY
OXFORD MS
38655-7349
US

IV. Provider business mailing address

11005 COVINGTON WAY
OXFORD MS
38655-7349
US

V. Phone/Fax

Practice location:
  • Phone: 601-842-5197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN MATTHEW WUERDEMAN
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 601-842-5197