Healthcare Provider Details

I. General information

NPI: 1649805425
Provider Name (Legal Business Name): MR. NORRIS LAYNE DELOSTRICO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1786 KINOOLE ST
HILO HI
96720-5245
US

IV. Provider business mailing address

PO BOX 54
MOUNTAIN VIEW HI
96771-0054
US

V. Phone/Fax

Practice location:
  • Phone: 808-959-5855
  • Fax:
Mailing address:
  • Phone: 808-960-6196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: