Healthcare Provider Details

I. General information

NPI: 1104641489
Provider Name (Legal Business Name): KIDS INDIVIDUAL DEVELOPMENT SERVICES HI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BISHOP ST STE 2685A
HONOLULU HI
96813-3404
US

IV. Provider business mailing address

922 NW CIRCLE BLVD STE 160-112
CORVALLIS OR
97330-1483
US

V. Phone/Fax

Practice location:
  • Phone: 623-321-2811
  • Fax: 541-275-0228
Mailing address:
  • Phone: 541-253-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ERIKA DREHER
Title or Position: CONTROLLER
Credential:
Phone: 541-253-2115