Provider Demographics
NPI:1376962621
Name:LEGACY HEALTHCARE
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPTA
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:FLORENE
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPTA
Authorized Official - Phone:336-307-6056
Mailing Address - Street 1:3001 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2815
Mailing Address - Country:US
Mailing Address - Phone:919-424-5080
Mailing Address - Fax:
Practice Address - Street 1:3001 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2815
Practice Address - Country:US
Practice Address - Phone:919-424-5080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2870320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities