=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942980156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALE LEGACY HEALTH COACHING AND FITNESS LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2023
-----------------------------------------------------
Last Update Date | 07/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9737 DOMINION CREST DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-654-5154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9737 DOMINION CREST DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-654-5154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAIYA I KEELING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-065-4051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Y00000X
-----------------------------------------------------
Taxonomy Name | Clinical Exercise Physiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------