Provider Demographics
NPI:1629407036
Name:LEGACY HEALTHCARE
Entity Type:Organization
Organization Name:LEGACY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL & VP OF HUMAN RES.
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1919-424-5086
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:
Mailing Address - Fax:
Practice Address - Street 1:106 MOUNT VISTA RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:NC
Practice Address - Zip Code:27239-8793
Practice Address - Country:US
Practice Address - Phone:336-859-0773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1089314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility