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General NPI Number Information
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NPI Number | 1932748498
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Entity Type | Organization
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Legal Business Name | LEGACY PHYSICAL THERAPY AND WELLNESS LLC
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Dates
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Enumeration Date | 01/02/2020
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Last Update Date | 07/16/2021
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Provider Practice Location Address
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Address Line | 351 N BYRON NELSON BLVD SUITE 110
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City | ROANOKE
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State | TX
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Zip | 76262
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Country | US
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Telephone | 254-855-3156
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Fax |
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Provider Business Mailing Address
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Address Line | 351 W BYRON NELSON BLVD STE 110
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City | ROANOKE
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State | TX
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Zip | 76262-3514
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Country | US
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Telephone | 817-756-5366
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KELLEY LEE HALE
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Credential | PT,DPT
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Telephone | 254-855-3156
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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