1083891469 NPI number — KA IMI PONO, LLC

Table of content: (NPI 1083891469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083891469 NPI number — KA IMI PONO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KA IMI PONO, 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:
1083891469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 161191
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96816-0925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-387-5307
Provider Business Mailing Address Fax Number:
808-218-7884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1029 KAPAHULU AVE STE 405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96816-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-387-5307
Provider Business Practice Location Address Fax Number:
808-218-7884
Provider Enumeration Date:
01/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TICE
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
808-387-5307

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  899 , 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: 1225133481 . This is a "PERSONAL NPI" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".