Healthcare Provider Details

I. General information

NPI: 1265172399
Provider Name (Legal Business Name): LEGACY FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 E AZTEC AVE STE 6
GALLUP NM
87301-4946
US

IV. Provider business mailing address

PO BOX 402
LUPTON AZ
86508-1402
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRETT HARTLINE
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-498-9086