Provider Demographics
NPI:1003167446
Name:LEGACY RECOVERY
Entity Type:Organization
Organization Name:LEGACY RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-300-8091
Mailing Address - Street 1:168 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-7655
Mailing Address - Country:US
Mailing Address - Phone:225-300-8091
Mailing Address - Fax:225-302-7462
Practice Address - Street 1:168 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-7655
Practice Address - Country:US
Practice Address - Phone:225-300-8091
Practice Address - Fax:225-302-7462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA507320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA507OtherSTATE LICENSE NUMBER