Provider Demographics
NPI:1437280153
Name:CDCR-PBSP
Entity Type:Organization
Organization Name:CDCR-PBSP
Other - Org Name:PELICAN BAY STATE PRISON
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH CARE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-465-1000
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95532-0001
Mailing Address - Country:US
Mailing Address - Phone:707-465-1000
Mailing Address - Fax:
Practice Address - Street 1:5905 LAKE EARL DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95532-0001
Practice Address - Country:US
Practice Address - Phone:707-465-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA043460261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health