Provider Demographics
| NPI: | 1902827272 |
|---|---|
| Name: | LEGACY CLINICS LLC |
| Entity Type: | Organization |
| Organization Name: | LEGACY CLINICS LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CFO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | ANNA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | LOOMIS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 503-415-5730 |
| Mailing Address - Street 1: | PO BOX 3777 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PORTLAND |
| Mailing Address - State: | OR |
| Mailing Address - Zip Code: | 97208-3777 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 503-413-3958 |
| Mailing Address - Fax: | 503-413-3212 |
| Practice Address - Street 1: | 1130 NW 22ND AVE STE 220 |
| Practice Address - Street 2: | |
| Practice Address - City: | PORTLAND |
| Practice Address - State: | OR |
| Practice Address - Zip Code: | 97210-2969 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 503-413-2901 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-22 |
| Last Update Date: | 2022-12-22 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 176B00000X, 207Q00000X, 207QG0300X, 207R00000X, 207RC0200X, 207T00000X, 207VM0101X, 207VX0000X, 207X00000X, 2083P0901X, 2085R0202X, 2086S0129X, 208M00000X, 261QM0801X | ||
| OR | 698327-81 | 261QM1300X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 176B00000X | Other Service Providers | Midwife | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
| No | 207VX0000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 2083P0901X | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OR | 277799 | Medicaid | |
| OR | 022930 | Medicaid | |
| OR | 804702000 | Other | REGENCE BLUE CROSS |
| OR | 286709 | Medicaid | |
| WA | 7101124 | Medicaid | |
| WA | 9646449 | Medicaid | |
| OR | 286822 | Medicaid | |
| OR | 286717 | Medicaid | |
| OR | 227592 | Medicaid | |
| OR | 277776 | Medicaid | |
| OR | 134334 | Medicaid | |
| OR | 226982 | Medicaid | |
| OR | 227692 | Medicaid | |
| WA | 7098429 | Medicaid | |
| OR | 286482 | Medicaid | |
| WA | 7130628 | Medicaid | |
| OR | 022930 | Medicaid | |
| OR | 134334 | Medicaid | |
| OR | 286482 | Medicaid |
