Healthcare Provider Details

I. General information

NPI: 1770107898
Provider Name (Legal Business Name): LEGACY VASCULAR LABS OF AMERICA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7711 SAN JACINTO PL STE 200
PLANO TX
75024-3296
US

IV. Provider business mailing address

PO BOX 191634
DALLAS TX
75219-8503
US

V. Phone/Fax

Practice location:
  • Phone: 972-345-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN RYAN
Title or Position: MANAGING MEMBER
Credential:
Phone: 972-345-7890