Provider Demographics
NPI:1902059538
Name:LEGACY LABORATORY SERVICES, LLC
Entity Type:Organization
Organization Name:LEGACY LABORATORY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VUCKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5730
Mailing Address - Street 1:PO BOX 5337
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5337
Mailing Address - Country:US
Mailing Address - Phone:503-413-4420
Mailing Address - Fax:503-413-4405
Practice Address - Street 1:1225 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2003
Practice Address - Country:US
Practice Address - Phone:503-413-5050
Practice Address - Fax:503-413-3212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY EMANUEL HOSPITAL AND HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-28
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D0625165291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146130Medicare PIN
ORR146131Medicare PIN
ORR146129Medicare PIN