Provider Demographics
NPI:1063146207
Name:TETRAD LEGACY
Entity type:Organization
Organization Name:TETRAD LEGACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELYSA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-904-5416
Mailing Address - Street 1:17920 HUFFMEISTER RD STE 250
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-4284
Mailing Address - Country:US
Mailing Address - Phone:281-213-4302
Mailing Address - Fax:346-818-2016
Practice Address - Street 1:17920 HUFFMEISTER RD STE 250
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4284
Practice Address - Country:US
Practice Address - Phone:281-213-4302
Practice Address - Fax:346-818-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care