Healthcare Provider Details

I. General information

NPI: 1821343302
Provider Name (Legal Business Name): GEORGE LUCAS CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 WAIMANU ST STE 614
HONOLULU HI
96813-5267
US

IV. Provider business mailing address

875 WAIMANU ST STE 614
HONOLULU HI
96813-5267
US

V. Phone/Fax

Practice location:
  • Phone: 808-533-3936
  • Fax: 808-791-6198
Mailing address:
  • Phone: 808-533-3936
  • Fax: 808-791-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1479-09
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: