1750672572 NPI number — WASHINGTON STATE DEPARTMENT OF CORRECTIONS- CEDAR CREEK CORRECTIONS CE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750672572 NPI number — WASHINGTON STATE DEPARTMENT OF CORRECTIONS- CEDAR CREEK CORRECTIONS CE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON STATE DEPARTMENT OF CORRECTIONS- CEDAR CREEK CORRECTIONS CE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750672572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41100, MAIL STOP 41100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98504-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-725-8213
Provider Business Mailing Address Fax Number:
360-586-1320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12200 BORDEAUX ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLEROCK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98556-0037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-359-4100
Provider Business Practice Location Address Fax Number:
360-664-3586
Provider Enumeration Date:
04/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CURL
Authorized Official First Name:
MARYANN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
509-318-3498

Provider Taxonomy Codes

  • Taxonomy code: 261QP2400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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