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General NPI Number Information
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NPI Number | 1780359653
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Entity Type | Organization
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Legal Business Name | LEGENDMED PLLC
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Dates
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Enumeration Date | 08/12/2021
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 140 N LITCHFIELD RD STE 110
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City | GOODYEAR
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State | AZ
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Zip | 85338-1226
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Country | US
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Telephone | 602-256-2525
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3394
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City | IDAHO FALLS
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State | ID
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Zip | 83403-3394
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Country | US
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Telephone | 208-525-2090
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Fax | 208-523-8978
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Authorized Official
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Title or Position | OWNER
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Name | KENNETH JORDAN WHITING
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Credential | CRNA
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Telephone | 512-201-9957
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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