Provider Demographics
NPI:1396075156
Name:PEOPLE OF COLOR NETWORK
Entity type:Organization
Organization Name:PEOPLE OF COLOR NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-253-3084
Mailing Address - Street 1:77 E THOMAS RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3115
Mailing Address - Country:US
Mailing Address - Phone:602-253-3084
Mailing Address - Fax:602-253-3732
Practice Address - Street 1:4520 N CENTRAL AVE
Practice Address - Street 2:SUITE 555 AND 565
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1828
Practice Address - Country:US
Practice Address - Phone:602-253-3084
Practice Address - Fax:602-265-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
AZBH3494251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ485908Medicaid