MEDICARE: LEGACY HEALTHCARE SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1245550060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HEALTHCARE SERVICES, INC

Provider Business Mailing Address
First Line	:	110 HORIZON DR STE 310
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-4926
Country	:	US
Telephone Number	:	919-424-5080
Fax Number	:	919-431-9224

Provider Business Practice Location Address
First Line	:	9642 BURKE LAKE RD
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-3052
Country	:	US
Telephone Number	:	703-543-7920
Fax Number	:	703-543-7924

Authorized Official
Title or Position	:	CFO
Name	:	MR. WILLIAM GIL WILSON JR.
Credential	:
Telephone Number	:	919-424-5080

Provider Enumeration Date	:	06/03/2010
Last Update Date	:	08/06/2021

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Directions to “LEGACY HEALTHCARE SERVICES, INC ” Practice Location

Language	Start Address	Practice Location

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