MEDICARE: IVORY LEGACY TRANSIT LLC

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	172A00000X	Driver

General Provider Information

NPI Number	:	1164365987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVORY LEGACY TRANSIT LLC

Provider Business Mailing Address
First Line	:	5814 WANAKAH DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77069-2645
Country	:	US
Telephone Number	:	713-907-3065
Fax Number	:

Provider Business Practice Location Address
First Line	:	5814 WANAKAH DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77069-2645
Country	:	US
Telephone Number	:	713-907-3065
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PORSHA HENDERSON
Credential	:
Telephone Number	:	713-907-3065

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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