=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154125755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 12TH AVE NE
-----------------------------------------------------
City | NORMAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73071-5238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-822-8458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 278
-----------------------------------------------------
City | BIXBY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74008-0278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-822-8458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ROBERT CORNELIUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-822-8458
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------