Basic Information
| Provider Information | |||||||||
| NPI: | 1194706986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEOPLE OF COLOR NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 EAST THOMAS ROAD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022533084 | ||||||||
| FaxNumber: | 6022533732 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 E.THOMAS ROAD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022533084 | ||||||||
| FaxNumber: | 6022533732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEON | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | TOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6022533084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | BH-2585 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 703547 | 01 | AZ | AHCCCS PROVIDER NUMBER | OTHER | BH2828 | 01 | AZ | ARIZONA BEHAVIORAL HEALTH | OTHER |