Healthcare Provider Details

I. General information

NPI: 1851764112
Provider Name (Legal Business Name): LEGACY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 S HIGHWAY 40
HEBER CITY UT
84032-3522
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 435-654-2500
  • Fax:
Mailing address:
  • Phone: 800-748-4868
  • Fax: 770-701-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number120505
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL DAGLEY
Title or Position: PRESIDENT
Credential: CRNA
Phone: 435-671-1254