Provider Demographics
NPI:1164713558
Name:WASHINGTON STATE PENITENTIARY
Entity Type:Organization
Organization Name:WASHINGTON STATE PENITENTIARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-725-8301
Mailing Address - Street 1:PO BOX 41107
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98504-1107
Mailing Address - Country:US
Mailing Address - Phone:360-725-8298
Mailing Address - Fax:360-586-1320
Practice Address - Street 1:1313 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-8817
Practice Address - Country:US
Practice Address - Phone:509-525-3610
Practice Address - Fax:509-526-6406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF CORRECTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health