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)

General Provider Information

NPI Number	:	1740909415
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	:	832-548-5000
Fax Number	:	832-779-8862

Provider Business Practice Location Address
First Line	:	10021 MAIN ST STE B3
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5254
Country	:	US
Telephone Number	:	832-548-5000
Fax Number	:	832-779-8862

Authorized Official
Title or Position	:	COO
Name	:	ROBERT PETER PALUSSEK
Credential	:
Telephone Number	:	832-548-5000

Provider Enumeration Date	:	08/25/2022
Last Update Date	:	01/08/2025

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