Basic Information
| Provider Information | |||||||||
| NPI: | 1649487729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF CALIFORNIA PRISON INDUSTRY AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 127 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945590127 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 23370 ROAD 22 | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596656100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHAZTER | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | BRANCH MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9163581721 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | PIA000103 | 05 | CA | MEDICAID |