Healthcare Provider Details

I. General information

NPI: 1194706986
Provider Name (Legal Business Name): PEOPLE OF COLOR NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 E.THOMAS ROAD SUITE 230
PHOENIX AZ
85012-3100
US

IV. Provider business mailing address

77 EAST THOMAS ROAD SUITE 230
PHOENIX AZ
85012-3100
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberBH-2585
License Number StateAZ

VIII. Authorized Official

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