Provider Demographics
NPI:1013250356
Name:LEGACY LABORATORY
Entity type:Organization
Organization Name:LEGACY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THINH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-292-7411
Mailing Address - Street 1:1544 SAWDUST RD
Mailing Address - Street 2:STE 280
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2929
Mailing Address - Country:US
Mailing Address - Phone:281-292-7411
Mailing Address - Fax:281-292-7481
Practice Address - Street 1:26010 OAK RIDGE DR
Practice Address - Street 2:STE 100
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1972
Practice Address - Country:US
Practice Address - Phone:281-292-7411
Practice Address - Fax:281-292-7481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54411291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory