Provider Demographics
NPI:1780181222
Name:DEPARTMENT OF STATE HOSPITAL COALINGA
Entity Type:Organization
Organization Name:DEPARTMENT OF STATE HOSPITAL COALINGA
Other - Org Name:COALINGA STATE HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-934-3201
Mailing Address - Street 1:24511 W JAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-9516
Mailing Address - Country:US
Mailing Address - Phone:559-935-4300
Mailing Address - Fax:
Practice Address - Street 1:24511 W JAYNE AVE
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-9516
Practice Address - Country:US
Practice Address - Phone:559-935-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health