1306190301 NPI number — DEPT. OF HEALTH-HAWAII-DEVELOPMENTAL DISABILITIES DIVISION CMU1

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306190301 NPI number — DEPT. OF HEALTH-HAWAII-DEVELOPMENTAL DISABILITIES DIVISION CMU1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPT. OF HEALTH-HAWAII-DEVELOPMENTAL DISABILITIES DIVISION CMU1
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:
1306190301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 PUNCHBOWL ST
Provider Second Line Business Mailing Address:
ROOM 463 ATTN: PHAO
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96813-2416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-587-6043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 KILAUEA AVE
Provider Second Line Business Practice Location Address:
ROOM 411 DDD-CMU 1
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96816-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-587-6043
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FRAY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
808-586-5842

Provider Taxonomy Codes

  • Taxonomy code: 261QD1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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