1194706986 NPI number — PEOPLE OF COLOR NETWORK

Table of content: (NPI 1194706986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194706986 NPI number — PEOPLE OF COLOR NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEOPLE OF COLOR NETWORK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194706986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 EAST THOMAS ROAD
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-253-3084
Provider Business Mailing Address Fax Number:
602-253-3732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 E.THOMAS ROAD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85012-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-253-3084
Provider Business Practice Location Address Fax Number:
602-253-3732
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LEON
Authorized Official First Name:
MANUEL
Authorized Official Middle Name:
TOMAS
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
602-253-3084

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  BH-2585 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 703547 . This is a "AHCCCS PROVIDER NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: BH2828 . This is a "ARIZONA BEHAVIORAL HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com