Healthcare Provider Details

I. General information

NPI: 1104735596
Provider Name (Legal Business Name): LEGACY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 S KELLY AVE BLDG F
EDMOND OK
73003-5659
US

IV. Provider business mailing address

609 S KELLY AVE BLDG F
EDMOND OK
73003-5659
US

V. Phone/Fax

Practice location:
  • Phone: 949-522-1469
  • Fax:
Mailing address:
  • Phone: 949-522-1469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOLTON BECKSTEAD
Title or Position: CFO
Credential:
Phone: 949-522-1469