1851307375 NPI number — FULL LIFE

Table of content: (NPI 1851307375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851307375 NPI number — FULL LIFE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FULL LIFE
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:
1851307375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/19/2007
NPI Reactivation Date:
01/12/2012

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75-6082 ALII DR STE 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KAILUA KONA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96740-2306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-322-9333
Provider Business Mailing Address Fax Number:
808-322-9334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75-6082 ALII DR STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAILUA KONA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96740-2306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-322-9333
Provider Business Practice Location Address Fax Number:
808-322-9334
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
808-322-9333

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 516990-01 . This is a "MEDICAID PROVIDER ID" identifier , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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