Provider Demographics
NPI:1427435163
Name:LEGACY HEALTH CARE SERVICES
Entity type:Organization
Organization Name:LEGACY HEALTH CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:314-971-8626
Mailing Address - Street 1:5809 ITASKA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3117
Mailing Address - Country:US
Mailing Address - Phone:314-971-8626
Mailing Address - Fax:
Practice Address - Street 1:45 E LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-3050
Practice Address - Country:US
Practice Address - Phone:314-200-2664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006973261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy