Basic Information
Provider Information | |||||||||
NPI: | 1528129442 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAMUEL MAHELONA MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4800 KAWAIHAU ROAD | ||||||||
Address2: |   | ||||||||
City: | KAPAA | ||||||||
State: | HI | ||||||||
PostalCode: | 96746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8083389431 | ||||||||
FaxNumber: | 8083389420 | ||||||||
Practice Location | |||||||||
Address1: | 4800 KAWAIHAU ROAD | ||||||||
Address2: |   | ||||||||
City: | KAPAA | ||||||||
State: | HI | ||||||||
PostalCode: | 96746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8083389431 | ||||||||
FaxNumber: | 8083389420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 11/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LORENZO | ||||||||
AuthorizedOfficialFirstName: | RACHELLE | ||||||||
AuthorizedOfficialMiddleName: | M D | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8083389431 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 27-N | HI | Y |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   |
ID Information
ID | Type | State | Issuer | Description | 592403 | 05 | HI |   | MEDICAID |