Basic Information
| Provider Information | |||||||||
| NPI: | 1104874619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAY CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KEAAU FAMILY HEALTH AND DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 KILAUEA AVE | ||||||||
| Address2: | STE 105 | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967203089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089614071 | ||||||||
| FaxNumber: | 8089615678 | ||||||||
| Practice Location | |||||||||
| Address1: | 16-192 PILI MUA ST | ||||||||
| Address2: | |||||||||
| City: | KEAAU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967498134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089300400 | ||||||||
| FaxNumber: | 8089615678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALAMEDA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8089614083 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 126800000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | HI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 592528 | 05 | HI | MEDICAID |