MEDICARE: LEGACY CLINIC WOODBURN

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	332900000X	Non-Pharmacy Dispensing Site	MD19203	OR

General Provider Information

NPI Number	:	1821260860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CLINIC WOODBURN

Provider Business Mailing Address
First Line	:	5626 OBERLIN DR
Second Line	:	SUITE 110
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 N BOONES FERRY RD
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-9602
Country	:	US
Telephone Number	:	503-981-9526
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	KENNY HEINE
Credential	:
Telephone Number	:	858-625-2990

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	10/22/2012

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