Basic Information
Provider Information | |||||||||
NPI: | 1891759338 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAHIAWA GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 128 LEHUA ST | ||||||||
Address2: |   | ||||||||
City: | WAHIAWA | ||||||||
State: | HI | ||||||||
PostalCode: | 967862036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086218411 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 128 LEHUA ST | ||||||||
Address2: |   | ||||||||
City: | WAHIAWA | ||||||||
State: | HI | ||||||||
PostalCode: | 967862036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086218411 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLDEN | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8086218411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WAHIAWA GENERAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 37-N | HI | Y |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0049036801 | 05 | HI |   | MEDICAID | 0018 | 01 | HI | TRICARE SNF ID | OTHER | 49036801 | 01 | HI | ALOHACARE | OTHER |