Healthcare Provider Details

I. General information

NPI: 1184960700
Provider Name (Legal Business Name): CA DEPARTMENT OF CORRECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SCOFIELD AVE
WASCO CA
93280-7515
US

IV. Provider business mailing address

25101 BEAR VALLEY RD
TEHACHAPI CA
93561-8311
US

V. Phone/Fax

Practice location:
  • Phone: 661-758-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS PETERSON
Title or Position: CHIEF OF MENTAL HEALTH (ACTING)
Credential: PH.D.
Phone: 661-758-8400