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General NPI Number Information
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NPI Number | 1043967466
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 03/05/2022
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Last Update Date | 09/16/2025
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Provider Practice Location Address
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Address Line | 1113 2ND AVE
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City | WEST LOGAN
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State | WV
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Zip | 25601-3309
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Country | US
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Telephone | 304-752-1900
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Fax | 304-752-0188
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Provider Business Mailing Address
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Address Line | 1113 2ND AVE
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City | WEST LOGAN
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State | WV
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Zip | 25601-3309
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Country | US
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Telephone | 304-752-1900
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Fax | 304-752-0188
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | WENDY WHITE
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Credential |
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Telephone | 304-688-7027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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