Provider Demographics
NPI:1013789171
Name:LEGACY CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:LEGACY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-376-5784
Mailing Address - Street 1:4073 LAVISTA RD STE 371
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5221
Mailing Address - Country:US
Mailing Address - Phone:770-376-5784
Mailing Address - Fax:770-376-5789
Practice Address - Street 1:4073 LAVISTA RD STE 371
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5221
Practice Address - Country:US
Practice Address - Phone:770-376-5784
Practice Address - Fax:770-376-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty