Healthcare Provider Details

I. General information

NPI: 1730832031
Provider Name (Legal Business Name): LEGACY MEDICAL SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OAK ST NE STE 7-B
ALBUQUERQUE NM
87106-4740
US

IV. Provider business mailing address

200 OAK ST NE STE 7-B
ALBUQUERQUE NM
87106-4740
US

V. Phone/Fax

Practice location:
  • Phone: 505-420-6979
  • Fax:
Mailing address:
  • Phone: 505-420-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIE D CAGLEY
Title or Position: CEO
Credential:
Phone: 714-421-9431