Basic Information
| Provider Information | |||||||||
| NPI: | 1396075156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEOPLE OF COLOR NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 E THOMAS RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022533084 | ||||||||
| FaxNumber: | 6022533732 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 N CENTRAL AVE | ||||||||
| Address2: | SUITE 555 AND 565 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022533084 | ||||||||
| FaxNumber: | 6022653280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2009 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEON | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | TOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022533084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | BH3494 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 485908 | 05 | AZ | MEDICAID |