Provider Demographics
NPI:1114539046
Name:LEGACY DIAGNOSTIC LAB LLC
Entity Type:Organization
Organization Name:LEGACY DIAGNOSTIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTHMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBDOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-755-9468
Mailing Address - Street 1:1651 N COLLINS BLVD # 135
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3658
Mailing Address - Country:US
Mailing Address - Phone:469-872-0008
Mailing Address - Fax:
Practice Address - Street 1:1651 N COLLINS BLVD # 135
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3658
Practice Address - Country:US
Practice Address - Phone:469-872-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory