Healthcare Provider Details

I. General information

NPI: 1326406315
Provider Name (Legal Business Name): LEGACY HEART CARE OF PHOENIX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 S MCCLINTOCK DR STE 120
TEMPE AZ
85282-7376
US

IV. Provider business mailing address

2500 WEST FWY STE 200
FORT WORTH TX
76102-5848
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-3700
  • Fax: 480-704-3741
Mailing address:
  • Phone: 817-426-4400
  • Fax: 817-423-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL B GRATCH
Title or Position: PRESIDENT
Credential:
Phone: 817-423-4400