Provider Demographics
NPI:1376689042
Name:CORNELL CORRECTIONS OF CALIFORNIA, INC.
Entity Type:Organization
Organization Name:CORNELL CORRECTIONS OF CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-276-7500
Mailing Address - Street 1:700 FOURMILE PKWY
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9114
Mailing Address - Country:US
Mailing Address - Phone:719-276-7500
Mailing Address - Fax:719-276-6961
Practice Address - Street 1:700 FOURMILE PKWY
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9114
Practice Address - Country:US
Practice Address - Phone:719-276-7500
Practice Address - Fax:719-276-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1526789322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42679249Medicaid
CO31487319Medicaid