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General NPI Number Information
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NPI Number | 1902111610
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Entity Type | Organization
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Legal Business Name | LEGACY MEDICAL LAB SERVICES, LLC
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Dates
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Enumeration Date | 08/18/2010
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Last Update Date | 04/04/2011
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Provider Practice Location Address
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Address Line | 688 ALLIANCE PKWY SUITE #200
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City | HEWITT
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State | TX
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Zip | 76643-3585
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Country | US
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Telephone | 254-420-4522
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Fax | 254-420-1144
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Provider Business Mailing Address
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Address Line | PO BOX 8
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City | HEWITT
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State | TX
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Zip | 76643-0008
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Country | US
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Telephone | 254-420-4522
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Fax | 254-420-1144
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MRS. LISA KAY RAHIMI
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Credential |
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Telephone | 254-732-3658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 45D2010680
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License Number State | TX
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