Provider Demographics
NPI:1386101855
Name:LEGACY INTEGRATIVE HEALTH
Entity type:Organization
Organization Name:LEGACY INTEGRATIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:469-362-8701
Mailing Address - Street 1:8900 OHIO DR STE B
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2262
Mailing Address - Country:US
Mailing Address - Phone:469-362-8701
Mailing Address - Fax:469-562-0059
Practice Address - Street 1:8900 OHIO DR STE B
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2262
Practice Address - Country:US
Practice Address - Phone:469-362-8701
Practice Address - Fax:469-562-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1356740740Medicaid
TX1477679926Medicaid
TX1710008966Medicaid