Provider Demographics
NPI:1942910724
Name:LEGACY THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:LEGACY THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:OSBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:423-762-8846
Mailing Address - Street 1:18270 SISKIYOU RD STE B
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1413
Mailing Address - Country:US
Mailing Address - Phone:760-991-3020
Mailing Address - Fax:
Practice Address - Street 1:18270 SISKIYOU RD STE B
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1413
Practice Address - Country:US
Practice Address - Phone:760-991-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CHILDREN'S CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033619580OtherMATTHEW OSBOURN NPI