Healthcare Provider Details

I. General information

NPI: 1972969806
Provider Name (Legal Business Name): LEGACY HEART CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 817-423-4400
  • Fax: 817-423-8080
Mailing address:
  • Phone: 817-423-4400
  • 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