Basic Information
Provider Information | |||||||||
NPI: | 1982973590 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KAPOLEI EARLY INTERVENTION PROGRAM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 92-461 MAKAKILO DR | ||||||||
Address2: |   | ||||||||
City: | KAPOLEI | ||||||||
State: | HI | ||||||||
PostalCode: | 967071270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 92-461 MAKAKILO DR | ||||||||
Address2: |   | ||||||||
City: | KAPOLEI | ||||||||
State: | HI | ||||||||
PostalCode: | 967071270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086783814 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2011 | ||||||||
LastUpdateDate: | 12/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MECHLING | ||||||||
AuthorizedOfficialFirstName: | MAJKEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8085361015 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X |   | HI | Y |   | Agencies | Early Intervention Provider Agency |   |
ID Information
ID | Type | State | Issuer | Description | 64676303 | 05 | HI |   | MEDICAID |