=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942842919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY HEALTHCARE SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2019
-----------------------------------------------------
Last Update Date | 10/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 PERKINS RD
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30268-2374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-463-2460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 SPRING FOREST RD STE 101
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-424-4312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICE
-----------------------------------------------------
Name | WILLIAM G WILSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-424-5080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------