Healthcare Provider Details

I. General information

NPI: 1891619573
Provider Name (Legal Business Name): AD LEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 N 22ND ST STE 30150
PHOENIX AZ
85016-4639
US

IV. Provider business mailing address

14 ATLAS CT
HUNTINGTON NY
11743-5416
US

V. Phone/Fax

Practice location:
  • Phone: 516-500-0519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DANIYAL QASIM
Title or Position: MEMBER
Credential:
Phone: 516-500-0519