MEDICARE: MULE CREEK SATE PRISON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	LCF35817	CA

General Provider Information

NPI Number	:	1730583311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULE CREEK SATE PRISON

Provider Business Mailing Address
First Line	:	9266 DAIRY CT
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95624-3583
Country	:	US
Telephone Number	:	209-274-4911
Fax Number	:

Provider Business Practice Location Address
First Line	:	9266 DAIRY CT
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95624-3583
Country	:	US
Telephone Number	:	209-274-4911
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVID SMILEY
Credential	:
Telephone Number	:	209-274-4911

Provider Enumeration Date	:	10/10/2014
Last Update Date	:	10/10/2014

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Directions to “MULE CREEK SATE PRISON ” Practice Location

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