Healthcare Provider Details

I. General information

NPI: 1205193893
Provider Name (Legal Business Name): FEDERAL CORRECTIONAL INSTITUTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37900 N 45TH AVE DEPT 1680
PHOENIX AZ
85086-7008
US

IV. Provider business mailing address

37900 N 45TH AVE DEPT 1680
PHOENIX AZ
85086-7008
US

V. Phone/Fax

Practice location:
  • Phone: 623-465-5797
  • Fax: 623-465-5116
Mailing address:
  • Phone: 623-465-5797
  • Fax: 623-465-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICARDO WILLIS
Title or Position: HEALTH SERVICES ADMINISTRATOR
Credential: ETC
Phone: 623-465-5163