Healthcare Provider Details

I. General information

NPI: 1710727565
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 N PORTLAND AVE
OKLAHOMA CITY OK
73134-4030
US

IV. Provider business mailing address

110 HORIZON DR STE 310
RALEIGH NC
27615-4926
US

V. Phone/Fax

Practice location:
  • Phone: 405-849-6489
  • Fax:
Mailing address:
  • Phone: 919-424-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM G WILSON JR.
Title or Position: CFO
Credential:
Phone: 919-424-5080