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

Table of content: MRS. CAROL ANN IADELUCA-MYRIANTHIS PT, PSYD (NPI 1477565745)

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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