=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205788338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY DIAGNOSTIC LABS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2026
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 TOLBERT PL
-----------------------------------------------------
City | PRINCEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27886-9615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-710-7830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 TOLBERT PL
-----------------------------------------------------
City | PRINCEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27886-9615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-710-7830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JESICKA ANDREWS
-----------------------------------------------------
Credential | ANDREWS
-----------------------------------------------------
Telephone | 252-366-3250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------