Provider Demographics
NPI:1164620084
Name:LEGACY HEALTHCARE SERVICES INC.
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE SERVICES INC.
Other - Org Name:LEGACY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GIL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:919-424-5080
Mailing Address - Street 1:110 HORIZON DR STE 310
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4926
Mailing Address - Country:US
Mailing Address - Phone:919-424-5080
Mailing Address - Fax:
Practice Address - Street 1:7100 W 13TH AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-4782
Practice Address - Country:US
Practice Address - Phone:303-770-4682
Practice Address - Fax:303-770-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO066646Medicare Oscar/Certification