Healthcare Provider Details

I. General information

NPI: 1942670005
Provider Name (Legal Business Name): LEGACY HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 TONGASS AVE
KETCHIKAN AK
99901-5635
US

IV. Provider business mailing address

3524 TONGASS AVE
KETCHIKAN AK
99901-5635
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-6355
  • Fax:
Mailing address:
  • Phone: 907-225-6355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1106
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number551
License Number StateAK

VIII. Authorized Official

Name: HELEN R KLEIN
Title or Position: OWNER
Credential: FNP
Phone: 907-225-6355