Basic Information
Provider Information | |||||||||
NPI: | 1194956839 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAIANAE DISTRICT COMPREHENSIVE HEALTH AND HOSPITAL BOARD, INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEARL CITY HALE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 86-260 FARRINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | WAIANAE | ||||||||
State: | HI | ||||||||
PostalCode: | 967923128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086973300 | ||||||||
FaxNumber: | 8086973687 | ||||||||
Practice Location | |||||||||
Address1: | 858 SECOND ST | ||||||||
Address2: |   | ||||||||
City: | PEARL CITY | ||||||||
State: | HI | ||||||||
PostalCode: | 967823342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086973300 | ||||||||
FaxNumber: | 8086973687 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2009 | ||||||||
LastUpdateDate: | 05/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHEN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | Z | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8086973300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | NA | HI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
ID | Type | State | Issuer | Description | 509119 | 05 | HI |   | MEDICAID |