Basic Information
| Provider Information | |||||||||
| NPI: | 1215359989 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE MOUNTAINS HAWAII, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KIPUKA O KE OLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 818 | ||||||||
| Address2: | |||||||||
| City: | KAMUELA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967430818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088855900 | ||||||||
| FaxNumber: | 8088856900 | ||||||||
| Practice Location | |||||||||
| Address1: | 64-1035 MAMALAHO HWY STE F | ||||||||
| Address2: | |||||||||
| City: | KAMUELA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967438440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088855900 | ||||||||
| FaxNumber: | 8088856900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2014 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEALOHA-BEAUDET | ||||||||
| AuthorizedOfficialFirstName: | CLAREN | ||||||||
| AuthorizedOfficialMiddleName: | KUULEI | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8088855900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 813669 | 05 | HI | MEDICAID |