| Organization Name: | CHUCKAWALA VALLWY STATE PRISON |
| NPI Number: | 1356701494 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MICHAEL LEE (CME) |
| Mailing Address: | 19025 Wileys Well Rd Blythe |
| State: | CA US |
| Postal Code: | 922252287 |
| Phone Number: | 7609225300 |
| Fax Number: | |
| NPI Enumeration Date: | 03/02/2016 |
| NPI Last Update Date: | 03/02/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2400X |
| License Number: | 63848 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Prison Health |
| Taxonomy Definition: | |