Provider Demographics
NPI:1265577100
Name:LEGACY, MARK DAVID (MED, ATC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:LEGACY
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HIGH ST # 32 MSC #
Mailing Address - Street 2:PE CENTER PLYMOUTH STATE UNIVERSITY
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1595
Mailing Address - Country:US
Mailing Address - Phone:603-535-2757
Mailing Address - Fax:
Practice Address - Street 1:17 HIGH ST # 32 MSC #
Practice Address - Street 2:PE CENTER PLYMOUTH STATE UNIVERSITY
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1595
Practice Address - Country:US
Practice Address - Phone:603-535-2757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH00032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer