1194706986 NPI number — PEOPLE OF COLOR NETWORK

Table of Contents

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".




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