Provider Demographics
NPI:1003620675
Name:LEGACY FAMILY CARE CLINIC LLC
Entity type:Organization
Organization Name:LEGACY FAMILY CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:601-596-9053
Mailing Address - Street 1:6798 U S HIGHWAY 98 STE 30
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-7987
Mailing Address - Country:US
Mailing Address - Phone:601-596-9053
Mailing Address - Fax:601-336-6615
Practice Address - Street 1:6798 U S HIGHWAY 98 STE 30
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-7987
Practice Address - Country:US
Practice Address - Phone:601-596-9053
Practice Address - Fax:601-336-6615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care