MEDICARE: LEGACY MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	155564-1205	UT

General Provider Information

NPI Number	:	1235266776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY MEDICAL PC

Provider Business Mailing Address
First Line	:	4400 S 700 E STE 140
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3053
Country	:	US
Telephone Number	:	801-288-0067
Fax Number	:	801-288-0067

Provider Business Practice Location Address
First Line	:	4400 S 700 E STE 140
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3053
Country	:	US
Telephone Number	:	801-288-0067
Fax Number	:	801-288-0067

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. OREN CLARON ALLDREDGE
Credential	:	MD
Telephone Number	:	801-288-0067

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	10/24/2007

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Directions to “LEGACY MEDICAL PC ” Practice Location

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