Basic Information
| Provider Information | |||||||||
| NPI: | 1689618308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAUAI CARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3326 160TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980086418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253924066 | ||||||||
| FaxNumber: | 4256231517 | ||||||||
| Practice Location | |||||||||
| Address1: | 9611 WAENA ROAD | ||||||||
| Address2: | |||||||||
| City: | KAUAI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083381681 | ||||||||
| FaxNumber: | 8083381297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | DEVORE | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4253924066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0-03831-1 | 05 | HI | MEDICAID |