Basic Information
| Provider Information | |||||||||
| NPI: | 1679524961 | ||||||||
| 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: | 8325485000 | ||||||||
| FaxNumber: | 7135593255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770062602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325485000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | HILLIARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8325485277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
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 |