Provider Demographics
NPI:1871237578
Name:THE PURPLE TRAIL CENTER LLC
Entity Type:Organization
Organization Name:THE PURPLE TRAIL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:HARROLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-518-4895
Mailing Address - Street 1:2601 W CLAREMONT ST APT 2070
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-6252
Mailing Address - Country:US
Mailing Address - Phone:480-518-4895
Mailing Address - Fax:
Practice Address - Street 1:2601 W CLAREMONT ST APT 2070
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-6252
Practice Address - Country:US
Practice Address - Phone:480-518-4895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities