Basic Information
| Provider Information | |||||||||
| NPI: | 1497987879 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRADEWINDS AT THE PONDS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PONDS AT PUNALU'U | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53-594 KAMEHAMEHA HWY | ||||||||
| Address2: | |||||||||
| City: | HAUULA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967179648 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 53-594 KAMEHAMEHA HWY | ||||||||
| Address2: | |||||||||
| City: | HAUULA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967179648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082931100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 08/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5035806925 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | W94691789-01 | 01 | HI | STATE OF HAWAII | OTHER |