MEDICARE: LEGACY HAVEN TEXAS 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1942168430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HAVEN TEXAS LLC

Provider Business Mailing Address
First Line	:	3180 SYCAMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1828
Country	:	US
Telephone Number	:	216-910-8977
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 SYCAMORE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1828
Country	:	US
Telephone Number	:	216-910-8977
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DISHELL GRAYS
Credential	:
Telephone Number	:	216-910-8977

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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Directions to “LEGACY HAVEN TEXAS LLC ” Practice Location

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