Basic Information
| Provider Information | |||||||||
| NPI: | 1386980696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY MEDICAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEGACY MEDICAL EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 EDISON DR | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135760262 | ||||||||
| FaxNumber: | 5135769459 | ||||||||
| Practice Location | |||||||||
| Address1: | 4303 LYONS RD. | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374588935 | ||||||||
| FaxNumber: | 9378472882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2012 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERDTNER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. FINANCE & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135760262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.