| Legacy Primary Care | |
|
11990 Grant St Ste 110 Northglenn CO 80233-1122 | |
| (720) 928-0244 | |
| (720) 928-0247 |
| Full Name | Legacy Primary Care |
|---|---|
| Speciality | Clinic/Center |
| Location | 11990 Grant St Ste 110, Northglenn, Colorado |
| Authorized Official Name and Position | Deric J Rachjaibun (OWNER) |
| Authorized Official Contact | 7209280244 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Legacy Primary Care 11990 Grant St Ste 110 Northglenn CO 80233-1122 Ph: (720) 928-0244 | Legacy Primary Care 11990 Grant St Ste 110 Northglenn CO 80233-1122 Ph: (720) 928-0244 |
| NPI Number | 1841090735 |
|---|---|
| Provider Enumeration Date | 03/18/2025 |
| Last Update Date | 03/18/2025 |
| Certification Date | 03/18/2025 |
| Medicare PECOS PAC ID | 2961927017 |
|---|---|
| Medicare Enrollment ID | O20250422000533 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841090735 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | () | Primary |
| Provider Name | Deric J Rachjaibun |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1902903933 PECOS PAC ID: 5193759306 Enrollment ID: I20050926001241 |
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