Provider Demographics
NPI:1447621685
Name:LEGACY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LEGACY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSLEY-CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-833-0000
Mailing Address - Street 1:1020 W ATHERTON DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-3470
Mailing Address - Country:US
Mailing Address - Phone:801-833-0000
Mailing Address - Fax:801-833-0001
Practice Address - Street 1:1020 W ATHERTON DR
Practice Address - Street 2:SUITE 220
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-3470
Practice Address - Country:US
Practice Address - Phone:801-833-0000
Practice Address - Fax:801-833-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty