Basic Information
| Provider Information | |||||||||
| NPI: | 1902827272 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY CLINICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133958 | ||||||||
| FaxNumber: | 5034133212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 NW 22ND AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207VM0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VX0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2083P0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 261QM1300X | 698327-81 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 286822 | 05 | OR | MEDICAID | 7130628 | 05 | WA | MEDICAID | 227592 | 05 | OR | MEDICAID | 277799 | 05 | OR | MEDICAID | 022930 | 05 | OR | MEDICAID | 226982 | 05 | OR | MEDICAID | 227692 | 05 | OR | MEDICAID | 277776 | 05 | OR | MEDICAID | 286709 | 05 | OR | MEDICAID | 286717 | 05 | OR | MEDICAID | 7101124 | 05 | WA | MEDICAID | 804702000 | 01 | OR | REGENCE BLUE CROSS | OTHER | 9646449 | 05 | WA | MEDICAID | 286482 | 05 | OR | MEDICAID | 134334 | 05 | OR | MEDICAID | 7098429 | 05 | WA | MEDICAID |