Provider Demographics
NPI:1699828103
Name:P.C. JAIL CLINIC
Entity type:Organization
Organization Name:P.C. JAIL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDERRAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-798-4033
Mailing Address - Street 1:910 TACOMA AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-2104
Mailing Address - Country:US
Mailing Address - Phone:253-798-4033
Mailing Address - Fax:253-798-4043
Practice Address - Street 1:910 TACOMA AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2104
Practice Address - Country:US
Practice Address - Phone:253-798-4033
Practice Address - Fax:253-798-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00034248OtherMEDICAL LICENSE