Healthcare Provider Details

I. General information

NPI: 1750121091
Provider Name (Legal Business Name): TRULOVECOMMUNITYCENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 05/24/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6617 S 57TH AVE
LAVEEN AZ
85339-2255
US

IV. Provider business mailing address

50 W BROADWAY STE 333
SALT LAKE CITY UT
84101-2027
US

V. Phone/Fax

Practice location:
  • Phone: 775-745-8276
  • Fax:
Mailing address:
  • Phone: 775-745-8276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: CLESTER VERA MARTIN
Title or Position: OWNER
Credential: BILLING/CODING
Phone: 775-745-8276