MEDICARE: LEGACY COMMUNITY HEALTH SERVICES, INC

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	261QF0400X	Federally Qualified Health Center (FQHC)

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	:	1174875470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY COMMUNITY HEALTH SERVICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 66308
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77266-6308
Country	:	US
Telephone Number	:	832-548-5076
Fax Number	:	713-523-4897

Provider Business Practice Location Address
First Line	:	4610 E CROSSTIMBERS ST
Second Line	:	KIPP DREAM PREP ACADEMY
City	:	HOUSTON
State	:	TX
Zip	:	77016-6337
Country	:	US
Telephone Number	:	713-636-6082
Fax Number	:	713-523-4897

Authorized Official
Title or Position	:	EXEC DIRECTOR
Name	:	KATHERINE CALDWELL
Credential	:
Telephone Number	:	832-548-5051

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	10/10/2012

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