Healthcare Provider Details

I. General information

NPI: 1376689042
Provider Name (Legal Business Name): CORNELL CORRECTIONS OF CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 FOURMILE PKWY
CANON CITY CO
81212-9114
US

IV. Provider business mailing address

700 FOURMILE PKWY
CANON CITY CO
81212-9114
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-7500
  • Fax: 719-276-6961
Mailing address:
  • Phone: 719-276-7500
  • Fax: 719-276-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number1526789
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number1526789
License Number StateCO

VIII. Authorized Official

Name: MR. JOSEPH WILNER
Title or Position: FACILITY DIRECTOR
Credential:
Phone: 719-276-7500