Basic Information
| Provider Information | |||||||||
| NPI: | 1457642076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALOHA HOUSE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CRISIS MOBILE OUTREACH-CAMHD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 IKE DR | ||||||||
| Address2: | |||||||||
| City: | MAKAWAO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967689718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085798414 | ||||||||
| FaxNumber: | 8085798426 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 IKE DR | ||||||||
| Address2: | |||||||||
| City: | MAKAWAO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967689718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085798414 | ||||||||
| FaxNumber: | 8085798426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2011 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SELMAN | ||||||||
| AuthorizedOfficialFirstName: | DARYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8085798414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALOHA HOUSE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 28STF | HI | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.