=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568863892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2014
-----------------------------------------------------
Last Update Date | 09/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 363 JUNGERMANN RD 261
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-5371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-244-3921
-----------------------------------------------------
Fax | 636-244-3922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 SPRING FOREST RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COTA/L REHAB DIRECTOR
-----------------------------------------------------
Name | BROOKE MARIE FRANKLIN
-----------------------------------------------------
Credential | COTA/L
-----------------------------------------------------
Telephone | 601-870-0618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2014012743
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------