Provider Demographics
NPI:1770769804
Name:LEGACY VISION PA
Entity type:Organization
Organization Name:LEGACY VISION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:E
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:972-208-5757
Mailing Address - Street 1:6909 COIT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024
Mailing Address - Country:US
Mailing Address - Phone:972-208-5757
Mailing Address - Fax:972-208-5548
Practice Address - Street 1:6909 COIT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024
Practice Address - Country:US
Practice Address - Phone:972-208-5757
Practice Address - Fax:972-208-5548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY VISION PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-18
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03489TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00825POtherMEDICARE
U25277Medicare UPIN