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General NPI Number Information
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NPI Number | 1073075438
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Entity Type | Organization
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Legal Business Name | LEGACY MEDICAL NETWORK LLC
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Dates
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Enumeration Date | 04/04/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 5797 BEECHCROFT RD STE F
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City | COLUMBUS
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State | OH
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Zip | 43229-2758
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Country | US
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Telephone | 614-377-0268
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Fax |
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Provider Business Mailing Address
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Address Line | 5797 BEECHCROFT RD STE F
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City | COLUMBUS
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State | OH
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Zip | 43229-2758
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSEPH KONIKA
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Credential |
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Telephone | 614-458-8283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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