=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124774203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUE LEGACY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2022
-----------------------------------------------------
Last Update Date | 02/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12702 TOEPPERWEIN RD STE 209
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-591-9494
-----------------------------------------------------
Fax | 210-957-7242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12702 TOEPPERWEIN RD STE 209
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-591-9494
-----------------------------------------------------
Fax | 210-957-7242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING LLC MEMBER
-----------------------------------------------------
Name | MS. LIANE N PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-591-9494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246RM2200X
-----------------------------------------------------
Taxonomy Name | Medical Laboratory Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------