Basic Information
| Provider Information | |||||||||
| NPI: | 1295225076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGEND HEALTHCARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E WARNER RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808973300 | ||||||||
| FaxNumber: | 4808973312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E WARNER RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808973300 | ||||||||
| FaxNumber: | 4808973312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2018 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4808973300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 2081P2900X | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.