Provider Demographics
NPI:1811411838
Name:LEGENDARY FAMILY HEALTHCARE PLLC
Entity Type:Organization
Organization Name:LEGENDARY FAMILY HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:623-666-3743
Mailing Address - Street 1:5372 N LONG RIFLE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-4215
Mailing Address - Country:US
Mailing Address - Phone:623-666-3743
Mailing Address - Fax:928-227-4110
Practice Address - Street 1:5372 N LONG RIFLE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-4215
Practice Address - Country:US
Practice Address - Phone:623-666-3743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty