MEDICARE: LEGACY NATIVE HOME CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1184385882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY NATIVE HOME CARE LLC

Provider Business Mailing Address
First Line	:	5235 S AXIOM
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-8529
Country	:	US
Telephone Number	:	480-245-4471
Fax Number	:

Provider Business Practice Location Address
First Line	:	5235 S AXIOM
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-8529
Country	:	US
Telephone Number	:	480-865-5244
Fax Number	:

Authorized Official
Title or Position	:	CEO/ MANAGER
Name	:	TYRESE TOMEGAH
Credential	:
Telephone Number	:	480-865-5244

Provider Enumeration Date	:	01/04/2022
Last Update Date	:	08/21/2025

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Directions to “LEGACY NATIVE HOME CARE LLC ” Practice Location

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