MEDICARE: LEGACY WOMEN'S CLINIC,PLLC

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	261QA0005X	Ambulatory Family Planning Facility	532543	TX

General Provider Information

NPI Number	:	1245575513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY WOMEN'S CLINIC,PLLC

Provider Business Mailing Address
First Line	:	4100 MCEWEN RD
Second Line	:	SUITE 130
City	:	DALLAS
State	:	TX
Zip	:	75244-5113
Country	:	US
Telephone Number	:	214-649-9346
Fax Number	:	214-295-9671

Provider Business Practice Location Address
First Line	:	4100 MCEWEN RD
Second Line	:	SUITE 130
City	:	DALLAS
State	:	TX
Zip	:	75244-5113
Country	:	US
Telephone Number	:	214-649-9346
Fax Number	:	214-295-9671

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MS. DORA LINDA BRADFORD
Credential	:	RN,BSN,WHNP, B-C
Telephone Number	:	214-649-9346

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	11/27/2012

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