Provider Demographics
NPI:1316811474
Name:LEGACY OF ALL IS WELL 365, LLC
Entity type:Organization
Organization Name:LEGACY OF ALL IS WELL 365, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:313-657-3558
Mailing Address - Street 1:49 TUXEDO ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3532
Mailing Address - Country:US
Mailing Address - Phone:313-657-3558
Mailing Address - Fax:
Practice Address - Street 1:49 TUXEDO ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3532
Practice Address - Country:US
Practice Address - Phone:313-657-3558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management