Healthcare Provider Details

I. General information

NPI: 1407790959
Provider Name (Legal Business Name): LEGACY MARTIAL ARTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 SCHOFIELD AVE STE A
SCHOFIELD WI
54476-6423
US

IV. Provider business mailing address

157087 TOWNLINE RD
WAUSAU WI
54403-5227
US

V. Phone/Fax

Practice location:
  • Phone: 715-971-4295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: AMANDA HANSON
Title or Position: OWNER/INSTRUCTOR
Credential:
Phone: 715-971-4295