Healthcare Provider Details

I. General information

NPI: 1902149776
Provider Name (Legal Business Name): LEGACY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1929 ROSSINI DR
VIRGINIA BEACH VA
23454-6638
US

IV. Provider business mailing address

PO BOX 645986
PITTSBURGH PA
15264-5257
US

V. Phone/Fax

Practice location:
  • Phone: 757-536-2246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: DESI-RAE HALL
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 757-251-9419