Provider Demographics
NPI:1336713858
Name:LEGACY CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:LEGACY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SYMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:206-313-3733
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-0002
Mailing Address - Country:US
Mailing Address - Phone:206-313-3733
Mailing Address - Fax:
Practice Address - Street 1:20 N FISHER PARK WAY STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4709
Practice Address - Country:US
Practice Address - Phone:206-313-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty