Provider Demographics
NPI:1700289642
Name:LEGACY TREATMENT CENTER
Entity Type:Organization
Organization Name:LEGACY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-560-5238
Mailing Address - Street 1:4421 STUART ANDREW BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1589
Mailing Address - Country:US
Mailing Address - Phone:954-560-5238
Mailing Address - Fax:888-510-9071
Practice Address - Street 1:3824 BARRETT DR
Practice Address - Street 2:SUITE 310
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7220
Practice Address - Country:US
Practice Address - Phone:954-560-5238
Practice Address - Fax:888-510-9071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-1265324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-060-1265OtherNC STATE LICENSE
NC34D2054739OtherCLIA