Provider Demographics
NPI:1205193893
Name:FEDERAL CORRECTIONAL INSTITUTION
Entity Type:Organization
Organization Name:FEDERAL CORRECTIONAL INSTITUTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:623-465-5163
Mailing Address - Street 1:37900 N 45TH AVE DEPT 1680
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-7008
Mailing Address - Country:US
Mailing Address - Phone:623-465-5797
Mailing Address - Fax:623-465-5116
Practice Address - Street 1:37900 N 45TH AVE DEPT 1680
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-7008
Practice Address - Country:US
Practice Address - Phone:623-465-5797
Practice Address - Fax:623-465-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal