Healthcare Provider Details

I. General information

NPI: 1215626981
Provider Name (Legal Business Name): BRILLIANT ARROWS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 W DUNLAP AVE SUITE B
PHOENIX AZ
85051
US

IV. Provider business mailing address

3612 W DUNLAP AVE SUITE B
PHOENIX AZ
85051
US

V. Phone/Fax

Practice location:
  • Phone: 602-469-9466
  • Fax:
Mailing address:
  • Phone: 602-469-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ERIN STARK
Title or Position: PARTNER/OWNER
Credential:
Phone: 317-225-0489