1770769804 NPI number — LEGACY VISION PA

Table of content: (NPI 1770769804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770769804 NPI number — LEGACY VISION PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY VISION PA
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:
1770769804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6909 COIT RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-208-5757
Provider Business Mailing Address Fax Number:
972-208-5548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6909 COIT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-208-5757
Provider Business Practice Location Address Fax Number:
972-208-5548
Provider Enumeration Date:
01/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
TRISH
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
972-208-5757

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  03489TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00825P . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com