Provider Demographics
NPI:1922425511
Name:G J & K LEGACY ENTERPRISES, INC
Entity Type:Organization
Organization Name:G J & K LEGACY ENTERPRISES, INC
Other - Org Name:CUSTOMIZED THERAPY SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ALT ADMINISTRATOR, BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:281-795-1061
Mailing Address - Street 1:P.O. BOX 57697
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598
Mailing Address - Country:US
Mailing Address - Phone:832-871-2105
Mailing Address - Fax:
Practice Address - Street 1:12302 CARMEL DALE LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-5719
Practice Address - Country:US
Practice Address - Phone:832-871-2105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:G J & K LEGACY ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-21
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668536251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health