Provider Demographics
NPI:1043967466
Name:LEGACY FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:LEGACY FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-688-7027
Mailing Address - Street 1:214 HANGING ROCK HWY
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-5102
Mailing Address - Country:US
Mailing Address - Phone:304-784-4495
Mailing Address - Fax:304-688-9020
Practice Address - Street 1:214 HANGING ROCK HWY
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-5102
Practice Address - Country:US
Practice Address - Phone:304-784-4495
Practice Address - Fax:304-688-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVAPRN66417OtherFNP