Healthcare Provider Details

I. General information

NPI: 1306361241
Provider Name (Legal Business Name): KAHALA CLINIC INTENSIVE TREATMENT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WAIALAE AVE STE 208
HONOLULU HI
96816-5312
US

IV. Provider business mailing address

4211 WAIALAE AVE STE 208
HONOLULU HI
96816-5312
US

V. Phone/Fax

Practice location:
  • Phone: 808-888-5228
  • Fax: 808-732-6433
Mailing address:
  • Phone: 808-888-5228
  • Fax: 808-732-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberGE-090-260-8896-01
License Number StateHI

VIII. Authorized Official

Name: DR. JASON RICHARD KEIFER
Title or Position: PRESIDENT
Credential: MD
Phone: 808-888-5228