Healthcare Provider Details

I. General information

NPI: 1558583856
Provider Name (Legal Business Name): KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 LINAPUNI ST BLDG A
HONOLULU HI
96819-3569
US

IV. Provider business mailing address

2239 N SCHOOL ST
HONOLULU HI
96819-2539
US

V. Phone/Fax

Practice location:
  • Phone: 808-791-9400
  • Fax: 808-848-0979
Mailing address:
  • Phone: 808-791-9400
  • Fax: 808-848-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number261QH0100X
License Number StateHI

VIII. Authorized Official

Name: DR. DAVID DERAUF
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 808-791-9400