Basic Information
| Provider Information | |||||||||
| NPI: | 1770852840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY MEDICAL IMAGING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 SW H K DODGEN LOOP | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765021814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542982490 | ||||||||
| FaxNumber: | 2547787197 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W HWY 6 | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767105591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547419729 | ||||||||
| FaxNumber: | 2543990669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2011 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | MADSEN | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2542982490 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS OF KING'S DAUGHTERS, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.