Provider Demographics
NPI:1407736820
Name:THE LEGACY HAUS
Entity type:Organization
Organization Name:THE LEGACY HAUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COSMOTOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:PRAYLAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHELLS
Authorized Official - Suffix:
Authorized Official - Credentials:SPECIALIST
Authorized Official - Phone:662-419-6369
Mailing Address - Street 1:930 COUNTY ROAD 600
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:MS
Mailing Address - Zip Code:38868-9239
Mailing Address - Country:US
Mailing Address - Phone:662-419-6369
Mailing Address - Fax:
Practice Address - Street 1:3195 MCCULLOUGH BLVD
Practice Address - Street 2:
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-8311
Practice Address - Country:US
Practice Address - Phone:662-350-0311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier