Basic Information
Provider Information | |||||||||
NPI: | 1063406155 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVALON CARE CENTER - HALE NANI LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HALE NANI REHABILITATION & NURSING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 206 N 2100 W | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841164740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015968844 | ||||||||
FaxNumber: | 8015969001 | ||||||||
Practice Location | |||||||||
Address1: | 1677 PENSACOLA ST | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968222676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085373371 | ||||||||
FaxNumber: | 8085325283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2005 | ||||||||
LastUpdateDate: | 08/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIRTON | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/CHAIRMAN | ||||||||
AuthorizedOfficialTelephone: | 8015968844 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | OHCA#64-N | HI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 04465901 | 05 | HI |   | MEDICAID |