Basic Information
Provider Information | |||||||||
NPI: | 1477226868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORCHID ISLE WELLNESS CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 233 HOOKANO ST | ||||||||
Address2: |   | ||||||||
City: | HILO | ||||||||
State: | HI | ||||||||
PostalCode: | 967206216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704133776 | ||||||||
FaxNumber: | 8335361752 | ||||||||
Practice Location | |||||||||
Address1: | 233 HOOKANO ST | ||||||||
Address2: |   | ||||||||
City: | HILO | ||||||||
State: | HI | ||||||||
PostalCode: | 967206216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704133776 | ||||||||
FaxNumber: | 8335361752 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2021 | ||||||||
LastUpdateDate: | 02/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COX | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9704133776 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | APRN | ||||||||
NPICertificationDate: | 02/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.