Provider Demographics
NPI:1518040146
Name:LEGACIE, TERRY (OD)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:LEGACIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-0181
Mailing Address - Country:US
Mailing Address - Phone:402-334-9511
Mailing Address - Fax:402-334-1070
Practice Address - Street 1:12330 K PLZ STE 109
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2270
Practice Address - Country:US
Practice Address - Phone:402-334-9511
Practice Address - Fax:402-334-1070
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025340500Medicaid
NEU29751Medicare UPIN
NE10025340500Medicaid