Basic Information
| Provider Information | |||||||||
| NPI: | 1902149776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 645986 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152645257 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2901 S LYNNHAVEN RD STE 450 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234528524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575362246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2013 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | DESI-RAE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7572519419 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.