MEDICARE: AVALON CARE CENTER - HALE NANI LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	OHCA#64-N	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063406155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON CARE CENTER - HALE NANI LLC

Provider Business Mailing Address
First Line	:	206 N 2100 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4740
Country	:	US
Telephone Number	:	801-596-8844
Fax Number	:	801-596-9001

Provider Business Practice Location Address
First Line	:	1677 PENSACOLA ST
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96822-2676
Country	:	US
Telephone Number	:	808-537-3371
Fax Number	:	808-532-5283

Authorized Official
Title or Position	:	CEO/CHAIRMAN
Name	:	CHARLES KIRTON
Credential	:
Telephone Number	:	801-596-8844

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/17/2022

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