Healthcare Provider Details

I. General information

NPI: 1871237578
Provider Name (Legal Business Name): THE PURPLE TRAIL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 W CLAREMONT ST APT 2070
PHOENIX AZ
85017-6252
US

IV. Provider business mailing address

2601 W CLAREMONT ST APT 2070
PHOENIX AZ
85017-6252
US

V. Phone/Fax

Practice location:
  • Phone: 480-518-4895
  • Fax:
Mailing address:
  • Phone: 480-518-4895
  • 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 State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMIKA DENISE HARROLD
Title or Position: OWNER
Credential:
Phone: 480-518-4895