Basic Information
| Provider Information | |||||||||
| NPI: | 1164713558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON STATE PENITENTIARY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 41107 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985041107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607258298 | ||||||||
| FaxNumber: | 3605861320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 N 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993628817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253610 | ||||||||
| FaxNumber: | 5095266406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCDERMOTT | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTHCARE FINANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3607258301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF CORRECTIONS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Prison Health |
No ID Information.