Provider Demographics
NPI:1730832031
Name:LEGACY MEDICAL SPECIALIST LLC
Entity type:Organization
Organization Name:LEGACY MEDICAL SPECIALIST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-421-9431
Mailing Address - Street 1:200 OAK ST NE STE 7-B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4740
Mailing Address - Country:US
Mailing Address - Phone:505-420-6979
Mailing Address - Fax:
Practice Address - Street 1:200 OAK ST NE STE 7-B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4740
Practice Address - Country:US
Practice Address - Phone:505-420-6979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty