| Living Legacy Health Llc | |
|
7717 Paddock Ln Lewiston ID 83501-6291 | |
| (208) 503-3113 | |
| Not Available |
| Full Name | Living Legacy Health Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 7717 Paddock Ln, Lewiston, Idaho |
| Authorized Official Name and Position | John Rudolph (OWNER) |
| Authorized Official Contact | 2085033113 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Living Legacy Health Llc 2320 Thain Grade # 1016 Lewiston ID 83501-4115 Ph: (208) 503-3113 | Living Legacy Health Llc 7717 Paddock Ln Lewiston ID 83501-6291 Ph: (208) 503-3113 |
| NPI Number | 1891487997 |
|---|---|
| Provider Enumeration Date | 05/25/2023 |
| Last Update Date | 01/02/2024 |
| Medicare PECOS PAC ID | 2163885849 |
|---|---|
| Medicare Enrollment ID | O20240118001847 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891487997 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 207QG0300X | Family Medicine - Geriatric Medicine | (* (Not Available)) | Secondary |
| Provider Name | John Bradley Rudolph |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1548503022 PECOS PAC ID: 1759604309 Enrollment ID: I20170116000186 |
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