MEDICARE: LEGACY RECOVERY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	10734	TX
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center	10734	TX
5	261QM1300X	Multi-Specialty Clinic/Center	10734	TX
6	261QR0400X	Rehabilitation Clinic/Center	10734	TX
7	261QM0850X	Adult Mental Health Clinic/Center	10734	TX
8	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	10734	TX
9	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	3648-3655	TX
10	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	10734	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477993814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY RECOVERY HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 3342
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77383-3342
Country	:	US
Telephone Number	:	713-636-2964
Fax Number	:	713-636-9686

Provider Business Practice Location Address
First Line	:	388 W LITTLE YORK RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-1303
Country	:	US
Telephone Number	:	713-636-2964
Fax Number	:	713-636-9686

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ELIJAH JACQUES
Credential	:	LCDC-I
Telephone Number	:	713-636-2964

Provider Enumeration Date	:	06/30/2013
Last Update Date	:	03/24/2015

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Directions to “LEGACY RECOVERY HEALTH CENTER ” Practice Location

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