1477565745 NPI number — MRS. CAROL ANN IADELUCA-MYRIANTHIS PT, PSYD

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 1477565745 NPI number — MRS. CAROL ANN IADELUCA-MYRIANTHIS PT, PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IADELUCA-MYRIANTHIS
Provider First Name:
CAROL
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, PSYD
Provider Gender Code:
F

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:
1477565745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
339 ALAWAENA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILO
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96720-3506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-959-0877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15-2866 GOVERNMENT MAIN ROAD
Provider Second Line Business Practice Location Address:
PAHOA VILLAGE CENTER
Provider Business Practice Location Address City Name:
PAHOA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-965-0880
Provider Business Practice Location Address Fax Number:
808-965-0770
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  474 , 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: A19867 . This is a "HMSA KA'U" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: D19861 . This is a "HMSA PAHOA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 01853401 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01853402 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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