Provider Demographics
NPI:1841000361
Name:LEGACY FAMILY CARE PLLC
Entity type:Organization
Organization Name:LEGACY FAMILY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-717-3926
Mailing Address - Street 1:2952 SQUIRE CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6211
Mailing Address - Country:US
Mailing Address - Phone:248-763-6037
Mailing Address - Fax:
Practice Address - Street 1:23800 ORCHARD LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-2562
Practice Address - Country:US
Practice Address - Phone:248-997-5964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty