Provider Demographics
NPI:1649773235
Name:LEGACY CLINICAL & CONSULTING SERVICES, LLC
Entity Type:Organization
Organization Name:LEGACY CLINICAL & CONSULTING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHALETA
Authorized Official - Middle Name:
Authorized Official - Last Name:EPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-721-9715
Mailing Address - Street 1:PO BOX 38178
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-0978
Mailing Address - Country:US
Mailing Address - Phone:804-506-0271
Mailing Address - Fax:
Practice Address - Street 1:208 N 2ND AVE STE 1
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2703
Practice Address - Country:US
Practice Address - Phone:804-506-0271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health