Healthcare Provider Details

I. General information

NPI: 1841103892
Provider Name (Legal Business Name): LEGACY LIFE ENRICHMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 WOODCREST LN
GASTON SC
29053-9523
US

IV. Provider business mailing address

166 WOODCREST LN
GASTON SC
29053-9523
US

V. Phone/Fax

Practice location:
  • Phone: 803-413-3622
  • Fax:
Mailing address:
  • Phone: 803-413-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: LINDA WICKENS
Title or Position: OWNER
Credential:
Phone: 803-413-3622