1386944437 NPI number — MARIA CARIDAD ILAR-REVILLA COMMUNITY HEALTH CLINIC LLC

Table of content: (NPI 1386944437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386944437 NPI number — MARIA CARIDAD ILAR-REVILLA COMMUNITY HEALTH CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIA CARIDAD ILAR-REVILLA COMMUNITY HEALTH CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386944437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94-866 MOLOALO ST STE 1B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAIPAHU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96797-3354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-677-5832
Provider Business Mailing Address Fax Number:
808-671-9109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94-866 MOLOALO ST STE 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAIPAHU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96797-3354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-677-5832
Provider Business Practice Location Address Fax Number:
808-671-9109
Provider Enumeration Date:
10/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ILAR-REVILLA
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
CARIDAD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
808-677-5832

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  9394 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 078033-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".