1730472192 NPI number — LEGACY CLINICS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730472192 NPI number — LEGACY CLINICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY CLINICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LEGACY MEDICAL GROUP FIRWOOD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730472192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3777
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-413-3958
Provider Business Mailing Address Fax Number:
503-413-3212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36860 INDUSTRIAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97055-7371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-826-0206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HOFF
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
SENIOR VP AND CFO
Authorized Official Telephone Number:
503-415-5730

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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