Basic Information
| Provider Information | |||||||||
| NPI: | 1952066474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAIKIKI HEALTH | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | WAIKIKI HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 277 OHUA AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968153695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 277 OHUA AVE | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968153695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089224787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARUYAMA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8085378418 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAIKIKI HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1FDUF5GN5LED42948 | 01 | HI | VEHICLE REGISTRATION NUMBER | OTHER |