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General NPI Number Information
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NPI Number | 1780181222
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF STATE HOSPITAL COALINGA
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Dates
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Enumeration Date | 04/11/2018
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Last Update Date | 04/11/2018
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Provider Practice Location Address
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Address Line | 24511 W JAYNE AVE
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City | COALINGA
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State | CA
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Zip | 93210-9516
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Country | US
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Telephone | 559-935-4300
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Fax |
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Provider Business Mailing Address
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Address Line | 24511 W JAYNE AVE
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City | COALINGA
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State | CA
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Zip | 93210-9516
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Country | US
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Telephone | 559-935-4300
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. JEOUNG PARK
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Credential |
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Telephone | 559-934-3201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2400X
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Taxonomy Name | Prison Health Clinic/Center
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License Number |
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License Number State |
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