Basic Information
| Provider Information | |||||||||
| NPI: | 1629369095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COYOTE RIDGE CORRECTIONS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41107 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985041107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607258298 | ||||||||
| FaxNumber: | 3605861320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 N EPHRATA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNELL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993269601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095443549 | ||||||||
| FaxNumber: | 5095435809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCDERMOTT | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEALTHCARE FINANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3607258301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF CORRECTIONS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Prison Health |
No ID Information.