Basic Information
| Provider Information | |||||||||
| NPI: | 1174875470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY COMMUNITY HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485076 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Practice Location | |||||||||
| Address1: | 4610 E CROSSTIMBERS ST | ||||||||
| Address2: | KIPP DREAM PREP ACADEMY | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770166337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136366082 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | CALDWELL | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8325485051 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 080462703 | 05 | TX | MEDICAID |