Provider Demographics
NPI:1083591911
Name:LEGACY COMPREHENSIVE HEALTH MANAGEMENT LLC.
Entity type:Organization
Organization Name:LEGACY COMPREHENSIVE HEALTH MANAGEMENT LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:JOLETTE
Authorized Official - Last Name:MASON-DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-578-8334
Mailing Address - Street 1:302 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:NC
Mailing Address - Zip Code:27832-9784
Mailing Address - Country:US
Mailing Address - Phone:252-578-8334
Mailing Address - Fax:
Practice Address - Street 1:412 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-2320
Practice Address - Country:US
Practice Address - Phone:434-532-2164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health