Healthcare Provider Details

I. General information

NPI: 1922429422
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 KINSAUL WILLOUGHBY RD
GREENVILLE NC
27834-7157
US

IV. Provider business mailing address

1748 KINSAUL WILLOUGHBY RD
GREENVILLE NC
27834-7157
US

V. Phone/Fax

Practice location:
  • Phone: 252-864-3532
  • Fax:
Mailing address:
  • Phone: 252-864-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1421
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1421
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1421
License Number StateNC

VIII. Authorized Official

Name: ANGELA GRANT
Title or Position: GENERAL COUNSEL
Credential:
Phone: 919-424-5086