Provider Demographics
NPI:1770852840
Name:LEGACY MEDICAL IMAGING
Entity Type:Organization
Organization Name:LEGACY MEDICAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-298-2490
Mailing Address - Street 1:1905 SW H K DODGEN LOOP
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-1814
Mailing Address - Country:US
Mailing Address - Phone:254-298-2490
Mailing Address - Fax:254-778-7197
Practice Address - Street 1:601 W HWY 6
Practice Address - Street 2:SUITE 104
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5591
Practice Address - Country:US
Practice Address - Phone:254-741-9729
Practice Address - Fax:254-399-0669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS OF KING'S DAUGHTERS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology