1487010518 NPI number — LEGACY PRIMARY HEALTHCARE

Table of content: (NPI 1487010518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487010518 NPI number — LEGACY PRIMARY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY PRIMARY HEALTHCARE
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:
Provider Other Organization Name Type Code:
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:
1487010518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7202 W ROMERO POOLS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85743-5540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 CALLE PORTAL STE B260A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635-2998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-226-4338
Provider Business Practice Location Address Fax Number:
866-337-8432
Provider Enumeration Date:
01/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AMEEN
Authorized Official First Name:
JAMEELA
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
520-971-7781

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP4903 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 803226 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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