Provider Demographics
NPI:1902111610
Name:LEGACY MEDICAL LAB SERVICES, LLC
Entity Type:Organization
Organization Name:LEGACY MEDICAL LAB SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:RAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-732-3658
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-0008
Mailing Address - Country:US
Mailing Address - Phone:254-420-4522
Mailing Address - Fax:254-420-1144
Practice Address - Street 1:688 ALLIANCE PKWY
Practice Address - Street 2:SUITE #200
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3585
Practice Address - Country:US
Practice Address - Phone:254-420-4522
Practice Address - Fax:254-420-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2010680291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2010680OtherCLIA ID NUMBER
TX217525901Medicaid
TX22110OtherCOLA NUMBER
TX217525902Medicaid
TXCL1146Medicare PIN