Provider Demographics
NPI:1003703463
Name:LEGACY PROVIDER SERVICES
Entity type:Organization
Organization Name:LEGACY PROVIDER SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LABRADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-444-4896
Mailing Address - Street 1:1600 JOLLA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-3005
Mailing Address - Country:US
Mailing Address - Phone:915-474-5916
Mailing Address - Fax:
Practice Address - Street 1:1600 JOLLA DEL SOL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79911-3005
Practice Address - Country:US
Practice Address - Phone:872-444-4896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-19
Last Update Date:2025-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193200000XMedicaid
TX251E00000XMedicaid
TX253Z00000XMedicaid
TX251C00000XMedicaid
TX3747A0650XMedicaid
TX251B00000XMedicaid
TX3747P1801XMedicaid
TX3209800000XMedicaid
TX320600000XMedicaid
TX305R00000XMedicaid
TX385H00000XMedicaid