Provider Demographics
NPI:1184385882
Name:LEGACY NATIVE HOME CARE LLC
Entity type:Organization
Organization Name:LEGACY NATIVE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYRESE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOMEGAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-245-4471
Mailing Address - Street 1:5235 S AXIOM
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8529
Mailing Address - Country:US
Mailing Address - Phone:480-245-4471
Mailing Address - Fax:
Practice Address - Street 1:5235 S AXIOM
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-8529
Practice Address - Country:US
Practice Address - Phone:480-865-5244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness