MEDICARE: VCPHCS XXI, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM2800X	Methadone Clinic	L000000011850	TN
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1538505649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VCPHCS XXI, LLC

Provider Business Mailing Address
First Line	:	5001 SPRING VALLEY ROAD
Second Line	:	SUITE 600 EAST
City	:	DALLAS
State	:	TX
Zip	:	75244-3946
Country	:	US
Telephone Number	:	214-365-6100
Fax Number	:	214-365-6150

Provider Business Practice Location Address
First Line	:	2165 SPICER CV STE 5
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-5623
Country	:	US
Telephone Number	:	901-372-7878
Fax Number	:	901-372-9298

Authorized Official
Title or Position	:	CEO
Name	:	JAY HIGHAM
Credential	:
Telephone Number	:	214-365-6112

Provider Enumeration Date	:	05/15/2013
Last Update Date	:	12/27/2024

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