Healthcare Provider Details

I. General information

NPI: 1578960902
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 NUWAY CIR
LENOIR NC
28645-3656
US

IV. Provider business mailing address

3001 SPRING FOREST RD
RALEIGH NC
27616-2815
US

V. Phone/Fax

Practice location:
  • Phone: 828-758-7326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number9409
License Number StateNC

VIII. Authorized Official

Name: ANGELA GRANT
Title or Position: VP OF HUMAN RESOURCES
Credential: GENERAL COUNSEL
Phone: 919-424-5086