Healthcare Provider Details

I. General information

NPI: 1457296741
Provider Name (Legal Business Name): HALOULUWIWUDUK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WIYOT DR
LOLETA CA
95551-9640
US

IV. Provider business mailing address

1000 WIYOT DR
LOLETA CA
95551-9640
US

V. Phone/Fax

Practice location:
  • Phone: 707-733-5055
  • Fax:
Mailing address:
  • Phone: 707-733-5055
  • Fax: 707-733-5601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN R REEVES III
Title or Position: MANAGER
Credential: MHA
Phone: 808-214-7269