Healthcare Provider Details

I. General information

NPI: 1679916985
Provider Name (Legal Business Name): LANCASTER STATE PRISON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 W AVENUE J4 44750 60TH STREET WEST
LANCASTER CA
93536-6825
US

IV. Provider business mailing address

4133 W AVENUE J4 44750 60TH STREET WEST
LANCASTER CA
93536-6825
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-2000
  • Fax:
Mailing address:
  • Phone: 661-729-2000
  • Fax: 661-729-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberPSY14366
License Number StateCA

VIII. Authorized Official

Name: DR. CHRISTOPHER CORNELL
Title or Position: CHIEF OF MENTAL HEALTH
Credential: PSYD
Phone: 661-729-2000