Provider Demographics
NPI:1083356877
Name:LEGACY HEALING HEALTH COMMUNTY LLC
Entity Type:Organization
Organization Name:LEGACY HEALING HEALTH COMMUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:
Authorized Official - Last Name:NTIRENGANYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-692-0247
Mailing Address - Street 1:5203 N 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2815
Mailing Address - Country:US
Mailing Address - Phone:480-692-0247
Mailing Address - Fax:
Practice Address - Street 1:1526 W GLENDALE AVE STE 109
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-8576
Practice Address - Country:US
Practice Address - Phone:480-692-0247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health