Organization
LEGACY MEDICAL LAB SERVICES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA KAY RAHIMI (VICE PRESIDENT)
(254) 732-3658
Entity
Organization
Contact information
Practice address
688 ALLIANCE PKWY, SUITE #200, HEWITT, TX 76643-3585
(254) 420-4522
(254) 420-1144
Mailing address
PO BOX 8, HEWITT, TX 76643-0008
(254) 420-4522
(254) 420-1144
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
45D2010680
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
217525901
—
TX
05
—
217525902
—
TX
01
—
22110
COLA NUMBER
TX
01
—
45D2010680
CLIA ID NUMBER
TX
Enumeration date
08/18/2010
Last updated
04/04/2011
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