Basic Information
| Provider Information | |||||||||
| NPI: | 1013196344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MBSB HUALALAI, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGENCY AT HUALALAI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3326 160TH AVE SE STE 120 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980086418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253924066 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75-181 HUALALAI RD | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967401787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083297878 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEDDOE | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | BART | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4253924066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.