Basic Information
| Provider Information | |||||||||
| NPI: | 1992950216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MALAMA NA MAKUA A KEIKI | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MALAMA FAMILY RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790006 | ||||||||
| Address2: | |||||||||
| City: | PAIA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967790006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085798414 | ||||||||
| FaxNumber: | 8085798426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1931 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | MAKAWAO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967689718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088777117 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUNNINGHAM | ||||||||
| AuthorizedOfficialFirstName: | JUD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8085798414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.