Provider Demographics
NPI:1598340358
Name:LEGACY HEALTH CLINIC
Entity Type:Organization
Organization Name:LEGACY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:CIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG-HOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:701-720-0737
Mailing Address - Street 1:2033 LAKESIDE ST
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 20TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6452
Practice Address - Country:US
Practice Address - Phone:701-720-0737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center