Basic Information
Provider Information | |||||||||
NPI: | 1992730956 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAIANAE DISTRICT COMPREHENSIVE HEALTH AND HOSPITAL BOARD, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WAIANAE COAST COMPREHENSIVE HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 86-260 FARRINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | WAIANAE | ||||||||
State: | HI | ||||||||
PostalCode: | 967923128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086967081 | ||||||||
FaxNumber: | 8086967093 | ||||||||
Practice Location | |||||||||
Address1: | 86-260 FARRINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | WAIANAE | ||||||||
State: | HI | ||||||||
PostalCode: | 967923128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086967081 | ||||||||
FaxNumber: | 8086967093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 02/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHEN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | Z | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8086967081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA,CMPE | ||||||||
NPICertificationDate: | 02/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QE0002X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QF0050X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 00934901 | 05 | HI |   | MEDICAID |