Provider Demographics
NPI:1477993814
Name:LEGACY RECOVERY HEALTH CENTER
Entity type:Organization
Organization Name:LEGACY RECOVERY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC-I
Authorized Official - Phone:713-636-2964
Mailing Address - Street 1:PO BOX 3342
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77383-3342
Mailing Address - Country:US
Mailing Address - Phone:713-636-2964
Mailing Address - Fax:713-636-9686
Practice Address - Street 1:388 W LITTLE YORK RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77076-1303
Practice Address - Country:US
Practice Address - Phone:713-636-2964
Practice Address - Fax:713-636-9686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-30
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X
TX10734261QM0801X, 261QM0855X, 261QM1300X, 261QR0400X, 261QM0850X, 261QR0405X, 261QR0401X
TX3648-3655261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX326764301Medicaid