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General NPI Number Information
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NPI Number | 1073059838
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Entity Type | Organization
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Legal Business Name | NINETEENTH CIRCUIT COMMUNITY CORRECTIONS PROGRAM
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 216 WEST MAIN STREET
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City | GRAFTON
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State | WA
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Zip | 26351
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Country | US
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Telephone | 304-265-0351
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Fax | 304-265-0384
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Provider Business Mailing Address
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Address Line | 216 WEST MAIN STREET
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City | GRAFTON
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State | WA
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Zip | 26351
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Country | US
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Telephone | 304-265-0351
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Fax | 304-265-0384
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Authorized Official
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Title or Position | EXECUITVE DIRECTOR/PROJECT MANAGER
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Name | TAMELA C. NAROG
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Credential |
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Telephone | 304-265-0351
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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