Healthcare Provider Details

I. General information

NPI: 1033263488
Provider Name (Legal Business Name): PRESTON YOUTH CORRECTIONAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WATERMAN RD
IONE CA
95640-9701
US

IV. Provider business mailing address

201 WATERMAN RD
IONE CA
95640-9701
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-8275
  • Fax: 209-274-0865
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberLCF44606
License Number StateCA

VIII. Authorized Official

Name: KENNETH ERLEBUSCH
Title or Position: PHRM
Credential: RPH
Phone: 209-274-8275