Healthcare Provider Details

I. General information

NPI: 1265277115
Provider Name (Legal Business Name): LEGACY PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S COLUMBIA RD STE 114
GRAND FORKS ND
58201-5895
US

IV. Provider business mailing address

19580 SCOUT LN
SAINT ONGE SD
57779-7913
US

V. Phone/Fax

Practice location:
  • Phone: 701-516-4637
  • Fax: 877-651-1381
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HEIDI WILLIAMS
Title or Position: CRED SPEC
Credential:
Phone: 605-846-8239