Healthcare Provider Details

I. General information

NPI: 1093391252
Provider Name (Legal Business Name): MR. STEVE WALICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 ULULANI ST
HILO HI
96720-7814
US

IV. Provider business mailing address

51 LAIMANA ST
HILO HI
96720-2517
US

V. Phone/Fax

Practice location:
  • Phone: 808-888-9555
  • Fax:
Mailing address:
  • Phone: 808-888-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: