Provider Demographics
NPI:1659588739
Name:STATE OF CALIFORNIA PRISON INDUSTRY AUTHORITY
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA PRISON INDUSTRY AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BRANCH MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHATZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-358-1721
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-0127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5905 LAKE EARL DRIVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531
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:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPIA000101Medicaid