Provider Demographics
NPI:1033989272
Name:LEGACY WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:LEGACY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:405-615-8967
Mailing Address - Street 1:PO BOX 57390
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-7390
Mailing Address - Country:US
Mailing Address - Phone:405-506-9101
Mailing Address - Fax:405-936-0561
Practice Address - Street 1:927 SW D AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4530
Practice Address - Country:US
Practice Address - Phone:405-936-0504
Practice Address - Fax:405-936-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty