Provider Demographics
NPI:1053902148
Name:NATIVE INTERACTIVE COMMUNITY ENRICHMENT LLC
Entity type:Organization
Organization Name:NATIVE INTERACTIVE COMMUNITY ENRICHMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUVILLION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-290-3656
Mailing Address - Street 1:P.O. BOX 12901
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12223 E CLOUD RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-3424
Practice Address - Country:US
Practice Address - Phone:602-290-3656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL20736410OtherENTITY ID