Provider Demographics
NPI:1831539824
Name:LEGACY
Entity type:Organization
Organization Name:LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTA/L
Authorized Official - Phone:919-435-1284
Mailing Address - Street 1:2275 RUIN CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537
Mailing Address - Country:US
Mailing Address - Phone:252-492-0066
Mailing Address - Fax:
Practice Address - Street 1:2275 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-8732
Practice Address - Country:US
Practice Address - Phone:252-492-0066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5022314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5022OtherOTA/L