Healthcare Provider Details

I. General information

NPI: 1710567763
Provider Name (Legal Business Name): LEGACY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 S FORK LOOP
STUART VA
24171-2659
US

IV. Provider business mailing address

263 S FORK LOOP
STUART VA
24171-2659
US

V. Phone/Fax

Practice location:
  • Phone: 276-790-4649
  • Fax:
Mailing address:
  • Phone: 276-790-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNON WALKER HUFFMAN
Title or Position: CEO
Credential: QMHP
Phone: 276-790-4649