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General NPI Number Information
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NPI Number | 1851198212
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Entity Type | Organization
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Legal Business Name | SOUTH CORRECTIONAL ENTITY
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Dates
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Enumeration Date | 02/25/2025
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Last Update Date | 02/25/2025
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Provider Practice Location Address
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Address Line | 20817 17TH AVE S
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City | DES MOINES
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State | WA
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Zip | 98198-7665
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Country | US
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Telephone | 206-257-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 20817 17TH AVE S
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City | DES MOINES
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State | WA
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Zip | 98198-7665
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Country | US
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Telephone | 206-257-6200
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DEVON SCHRUM
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Credential |
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Telephone | 206-257-6262
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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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