Healthcare Provider Details

I. General information

NPI: 1518897560
Provider Name (Legal Business Name): LEGACY RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W332S9291 RED BRAE DR
MUKWONAGO WI
53149-9265
US

IV. Provider business mailing address

W332S9291 RED BRAE DR
MUKWONAGO WI
53149-9265
US

V. Phone/Fax

Practice location:
  • Phone: 936-615-0981
  • Fax: 323-580-0308
Mailing address:
  • Phone: 936-615-0981
  • Fax: 323-580-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MILLER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 936-615-0981