Healthcare Provider Details

I. General information

NPI: 1316277072
Provider Name (Legal Business Name): THE BOBBY BENSON CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 12/31/2009
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 NumberCA#53-STF
License Number StateHI

VIII. Authorized Official

Name: DR. MORRIS ANGUS GRAHAM
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 808-293-7555