Provider Demographics
NPI:1619594637
Name:LEGACY MEDICAL LLC
Entity Type:Organization
Organization Name:LEGACY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, OTR/L
Authorized Official - Phone:701-516-4637
Mailing Address - Street 1:PO BOX 13238
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208-3238
Mailing Address - Country:US
Mailing Address - Phone:701-516-4637
Mailing Address - Fax:877-651-1381
Practice Address - Street 1:600 S 2ND ST STE 200
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5729
Practice Address - Country:US
Practice Address - Phone:701-516-4637
Practice Address - Fax:877-651-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty