Healthcare Provider Details

I. General information

NPI: 1235373960
Provider Name (Legal Business Name): PEOPLE OF COLOR NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N CENTRAL AVE
PHOENIX AZ
85004-1722
US

IV. Provider business mailing address

77 E THOMAS RD STE 230
PHOENIX AZ
85012-3100
US

V. Phone/Fax

Practice location:
  • Phone: 602-251-0650
  • Fax: 602-251-0632
Mailing address:
  • Phone: 602-253-3084
  • Fax: 602-253-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MANUEL TOMAS LEON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 602-253-3084