Provider Demographics
NPI:1992115406
Name:LEGACY
Entity type:Organization
Organization Name:LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:HUMMER-WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:910-964-4764
Mailing Address - Street 1:3001SPRING FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:RALIEGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616
Mailing Address - Country:US
Mailing Address - Phone:919-424-5086
Mailing Address - Fax:919-424-5085
Practice Address - Street 1:3001 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2815
Practice Address - Country:US
Practice Address - Phone:919-424-5086
Practice Address - Fax:919-424-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5760313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC25000000Medicaid