Provider Demographics
NPI:1245575513
Name:LEGACY WOMEN'S CLINIC,PLLC
Entity Type:Organization
Organization Name:LEGACY WOMEN'S CLINIC,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:LINDA
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN,WHNP, B-C
Authorized Official - Phone:214-649-9346
Mailing Address - Street 1:4100 MCEWEN RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5113
Mailing Address - Country:US
Mailing Address - Phone:214-649-9346
Mailing Address - Fax:214-295-9671
Practice Address - Street 1:4100 MCEWEN RD
Practice Address - Street 2:SUITE 130
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5113
Practice Address - Country:US
Practice Address - Phone:214-649-9346
Practice Address - Fax:214-295-9671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX532543261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility