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General NPI Number Information
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NPI Number | 1407736820
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Entity Type | Organization
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Legal Business Name | THE LEGACY HAUS
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Dates
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Enumeration Date | 09/05/2025
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Last Update Date | 09/05/2025
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Provider Practice Location Address
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Address Line | 3195 MCCULLOUGH BLVD
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City | BELDEN
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State | MS
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Zip | 38826-8311
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Country | US
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Telephone | 662-350-0311
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Fax |
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Provider Business Mailing Address
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Address Line | 930 COUNTY ROAD 600
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City | SHANNON
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State | MS
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Zip | 38868-9239
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Country | US
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Telephone | 662-419-6369
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Fax |
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Authorized Official
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Title or Position | PROFESSIONAL COSMOTOLOGY
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Name | PRAYLAR R SHELLS
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Credential | SPECIALIST
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Telephone | 662-419-6369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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