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General NPI Number Information
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NPI Number | 1033601562
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Entity Type | Organization
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Legal Business Name | THE LEGACY GROUP FOUNDATION, INC
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/31/2018
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Provider Practice Location Address
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Address Line | 210 VANDEMERE RD UNIT A
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City | BAYBORO
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State | NC
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Zip | 28515-8010
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Country | US
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Telephone | 910-340-3630
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Fax | 910-597-1007
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Provider Business Mailing Address
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Address Line | 8 CARVER RD
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City | JACKSONVILLE
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State | NC
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Zip | 28540-7010
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Country | US
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Telephone | 910-340-3630
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Fax | 910-597-1007
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Authorized Official
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Title or Position | CEO
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Name | NICOLE DENICE BARNES
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Credential | CSAC
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Telephone | 910-340-3630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CSAC-3017
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License Number State | NC
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