Healthcare Provider Details

I. General information

NPI: 1306904461
Provider Name (Legal Business Name): BOBBY BENSON CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56-660 KAMEHAMEHA HWY
KAHUKU HI
96731-2210
US

IV. Provider business mailing address

56-660 KAMEHAMEHA HWY
KAHUKU HI
96731-2210
US

V. Phone/Fax

Practice location:
  • Phone: 808-293-7555
  • Fax: 808-293-7196
Mailing address:
  • Phone: 808-293-7555
  • Fax: 808-293-7196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number53-STF
License Number StateHI

VIII. Authorized Official

Name: MR. JEFFRIE WAGNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 808-293-7555