Healthcare Provider Details

I. General information

NPI: 1710504741
Provider Name (Legal Business Name): LEGACY HEALTHCARE SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

487 HIGHWAY 378
LEXINGTON SC
29072-9177
US

IV. Provider business mailing address

110 HORIZON DR STE 310
RALEIGH NC
27615-4926
US

V. Phone/Fax

Practice location:
  • Phone: 888-239-3467
  • Fax:
Mailing address:
  • Phone: 910-724-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM G WILSON JR.
Title or Position: CFO
Credential:
Phone: 919-424-4312