Provider Demographics
NPI:1518069913
Name:LEGACY HEALTHCARE SERVICES, INC.
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:919-424-5080
Mailing Address - Street 1:3001 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2817
Mailing Address - Country:US
Mailing Address - Phone:919-424-5080
Mailing Address - Fax:919-431-9224
Practice Address - Street 1:2800 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6403
Practice Address - Country:US
Practice Address - Phone:765-864-0237
Practice Address - Fax:765-864-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2019-05-23
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
IN156622Medicare Oscar/Certification