Organization
LEGACY MEDICAL GROUP, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TIARA SHACKLEFORD FNP (NURSE PRACTITIONER)
(336) 944-9950
Entity
Organization
Contact information
Practice address
302 POMONA DR STE L, GREENSBORO, NC 27407-1642
(336) 763-1980
Mailing address
302 POMONA DR STE L, GREENSBORO, NC 27407-1642
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
251F00000X
Home Infusion Agency
—
—
261QI0500X
Infusion Therapy Clinic/Center
—
—
261QP2300X
Primary Care Clinic/Center
—
—
Other
Enumeration date
03/22/2022
Last updated
03/22/2022
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