Provider Demographics
NPI:1467047258
Name:BLUEGRASS LEGACY HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:BLUEGRASS LEGACY HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-826-2265
Mailing Address - Street 1:105 GLEN OAK BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3058
Mailing Address - Country:US
Mailing Address - Phone:615-826-2265
Mailing Address - Fax:615-826-4616
Practice Address - Street 1:105 GLEN OAK BLVD STE 202
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3058
Practice Address - Country:US
Practice Address - Phone:615-826-2265
Practice Address - Fax:615-826-4616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4112769OtherBCBST